Archived: Dilip Sabnis PCT Medical Services (PCTMS) Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Dilip Sabnis on 23 November 2016. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

• There was no effective system in place for reporting, recording, investigating, responding and learning from significant events.
• There was an insufficient system in place to receive or respond to Medicine and Health products Regulatory Agency (MHRA) alerts.
• The practice did not have defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
• Risks to patients were not assessed and well managed. We found the infection prevention control audit was incomplete.
• Prescribing practices were unsafe and patients receiving high risk medicines had not been appropriately reviewed.
• Medicines were not being stored appropriately and cold chain procedure followed.
• Patient group directives had not been appropriately authorised for the administration of immunisations to pregnant women.
• Not all clinical staff had undertaken appropriate emergency life support training.
• The practice did not hold appropriate emergency medicines for patients allergic to penicillin and who may experience a diabetic hypoglycaemia episode.
• We found patients were inappropriately coded for conditions they did not have.
• The practice had no quality improvement processes in place to identify where they might improve.
• Care plans were not in place for all patients on their admission avoidance programme.
• Some referrals lacked relevant information and did not meet guidelines for referrals.
• Patients had not been appropriately identified, placed on risk registers and included in multidisciplinary discussions.
• Patients had not received appropriate medicine reviews.
• The practice was performing below averages in relation to most responses relating to involvement in decisions with the GPs.
• We found the practice performed infrequent home visits and did not schedule home visits to the most vulnerable such as those receiving end of life care.
• Patient satisfaction score were below the local and national average for the practice opening hours and easy of contacting the practice.
• The practice did not have an effective complaints procedure in place. It failed to advise patients of their right to advocacy services to support them making a complaint.
• There were no translation services available for patients whose first language was not English.
• The overarching governance systems for the practice had not been effectively embedded into the practice.
• The practice did not have a clear vision and strategy for delivering primary medical services.
• The practice had a number of policies and procedures to govern activity, but these were not reflective of the practice.
• There was a lack of clinical oversight. There were no checks to ensure that the GP locums were referring appropriately and prescribing in accordance with NICE guidelines.
• Staff had received training to undertake chaperone duties but had not received Disclosure and Barring Service (DBS) checks.

The areas where the provider must make improvements are:

• Ensure staff understand, recognise, record, investigate and identify and learn from significant incidents.
• Establish an effective system to action medicine safety alerts and monitor and prescribe safely in accordance with guidance.
• Undertake a risk assessment in relation to emergency medicines held at the practice to enable staff to respond to a medical emergency.
• Follow published guidance in relation to the storage of medicines in fridges.
• Ensure staff are suitably trained to undertake their roles, for example, receiving training in basic first aid.
• Ensure the appropriate supervision of clinical staff in the administration of vaccinations.
• Maintain accurate records on patients, including coding, completion of care plans and inclusion on risk registers to enable the monitoring of their health.
• Implement an effective system of governance and clinical oversight to assess, monitor and improve the quality of safety for patients and identify and mitigate risks relating to the health, safety and welfare of patients.
• Seek and act on patient feedback.
• Operate an effective and accessible complaint system.
• Implement a system of quality assurance to include clinical audit.
• Staff undertaking chaperone responsibilities should have disclosure and barring service checks or be risk assessed for the role.
• Ensure the secure storage of blank prescription stationery and record their issue to clinicians.

The area where the provider should make improvement is;

• Identify a system for improving the screening rates of bowel cancer.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice