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This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Requires improvement –––

DrDr Dixit'Dixit'ss PrPracticacticee (also(alsoknownknown asas DrDr DixitDixit && DrDr Kolla)Kolla)Quality Report

The Galleries Health Centre, Washington, Tyne andWear, NE38 7NQTel: 0191 502 6933Website: www.dixitkollagp.nhs.uk

Date of inspection visit: 28 April 2015Date of publication: 09/07/2015

1 Dr Dixit's Practice (also known as Dr Dixit & Dr Kolla) Quality Report 09/07/2015

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 6

What people who use the service say 9

Areas for improvement 9

Detailed findings from this inspectionOur inspection team 11

Background to Dr Dixit's Practice (also known as Dr Dixit & Dr Kolla) 11

Why we carried out this inspection 11

How we carried out this inspection 12

Detailed findings 13

Action we have told the provider to take 25

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Dr Dixit’s Practice on 28 April 2015. Specifically, wefound the practice to require improvement for providingsafe and effective services and for being well led. Theywere rated as good for providing caring and responsiveservices.

Our key findings across all the areas we inspected were asfollows:

• Staff were not clear about their responsibilities to raiseconcerns and report incidents and near misses.However, the practice had a process in place forreporting them.

• Some risks to patients and staff were not assessed andsystems and processes were not fully implemented tokeep patients safe. For example, there was norecruitment policy and the calibration of medicalequipment was out of date.

• Patients’ needs were assessed and care was plannedand delivered following best practice guidance. Wesaw a system of clinical audit to improve outcomes forpatients.

• Staff had not received training appropriate to theirroles; for example, they had not received fire or healthand safety training. There was an appraisal system inplace; however staff had not received an appraisalsince April 2013.

• Patients said they were treated with compassion,dignity and respect and they were involved indecisions about their care and treatment. Datashowed that patients rated the practice mostly higherthan the clinical commissioning group (CCG) averagesfor being caring.

• Most patients we spoke with and those whocompleted CQC comment cards indicated they feltthey could obtain appointments, including urgentappointments, when needed.

• Information about services and how to complain wasavailable and easy to understand.

Summary of findings


• The practice proactively sought feedback frompatients and had an active patient participation group(PPG)

• There was a vision and a strategy for the future and aleadership structure and staff felt supported bymanagement. However, some of the systems andprocesses which should have been in place to keeppatients and staff safe were not in place.

However, there were also areas of practice where theprovider needs to make improvements.

Importantly, the provider must:

• Ensure systems and processes are established andoperated effectively in order to assess, monitor andimprove the quality of service provided in carrying outthe regulated activities.

• Ensure staff receive appropriate training and appraisalin order to carry out the duties they perform.

• Ensure recruitment procedures are established andthat they operate effectively.

In addition the provider should:

• Take steps to monitor equipment to ensure it is in dateand suitable for use.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as requires improvement for providing safeservices as there are areas where they should make improvements.Some staff were not clear about their responsibilities to raiseconcerns, and to report incidents and near misses. However, therewas a process in place for reporting them. Some risks to patientswho used the services were assessed, however the systems andprocesses were not implemented well enough to ensure patientsand staff were kept safe. For example there was no recruitmentpolicy therefore, expectations, legislation and requirements for therecruitment of staff had not been followed. The calibration ofmedical equipment was out of date.

Requires improvement –––

Are services effective?The practice is rated as requires improvement for providing effectiveservices as there are areas where they should make improvements.Staff had not received training appropriate to their roles, for examplethey had not received fire or health and safety training. There was anappraisal system in place; however staff had not received anappraisal since April 2013. Data showed patient outcomes wereabove average for the locality. Staff referred to guidance fromNational Institute for Health and Care Excellence and used itroutinely. Patient’s needs were assessed and care was planned anddelivered in line with current legislation. This included assessingcapacity and promoting good health. We saw evidence that auditwas driving improvement in performance to improve patientoutcomes. Staff worked with multidisciplinary teams.


Are services caring?The practice is rated as good for providing caring services. Datashowed that patients rated the practice mostly higher than theclinical commissioning group (CCG) averages for being caring.Patients said they were treated with compassion, dignity andrespect and they were involved in decisions about their care andtreatment. Information to help patients understand the servicesavailable was easy to understand. We also saw that staff treatedpatients with kindness and respect, and maintained confidentiality.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Theyreviewed the needs of their local population to secureimprovements to services where these were identified. Mostpatients said they found it easy to make an appointment, with

Good –––

Summary of findings


urgent appointments available the same day. Information abouthow to complain was available and easy to understand andevidence showed that the practice responded to issues raised.Learning from complaints was shared with staff.

Are services well-led?The practice is rated as requires improvement for providing well-ledservices as there are areas where they should make improvements.They had a vision and a strategy for the future and knew how theywanted to improve the services they provided. There was aleadership structure and staff felt supported by management;however they had not received regular performance reviews or somemandatory training. The practice had some policies and proceduresto govern activity. There was a system of clinical audit in place toimprove patient outcomes. Regular staff meetings were held. Thepractice proactively sought feedback from patients and had anactive patient participation group (PPG).


Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe practice is rated as requires improvement for the care of olderpeople. There are aspects of the practice that require improvementand therefore this impacts on all population groups. All patientsover the age of 75 had a named GP and were invited to the practicefor an over 75 health check. Patients over the age of 65 were offeredthe pneumococcal and flu vaccine and attendance rates for this inthe last season were 94%. The health care assistant and practicenurse carried out home visits to patients who were unable to attendthe surgery during the winter flu vaccine season and were able toadminister the vaccine if appropriate and carryout a health check.The practice had a palliative care register and had monthlymultidisciplinary meetings to discuss patients and their families’care and support needs.


People with long term conditionsThe practice is rated as requires improvement for the care of peoplewith long-term conditions. There are aspects of the practice thatrequire improvement and therefore this impacts on all populationgroups. There were clinical leads for the management of long termconditions which were shared between the GPs and practice nurse.One of the GPs led on chronic obstructive pulmonary disease,(COPD), diabetes and mental health. The other led on palliative careand learning disabilities. There were practice nurse led clinics forCOPD and diabetes. There were recall systems in place and patientswere offered an annual health check. We saw the practice achievedmaximum Quality and Outcomes Framework (QOF) points availableto them for all of the chronic conditions, for example, 100% for COPDwhich was above the CCG and England averages by 2.9 and 4.8points. All patients with chronic conditions were offered apneumococcal and flu vaccines in the last year and the take up ratewas 76.9%.


Families, children and young peopleThe practice is rated as requires improvement for the care offamilies, children and young people. There are aspects of thepractice that require improvement and therefore this impacts on allpopulation groups. The practice offered child health clinics forchildren under the age of five in conjunction with the health visitor,practice nurse and a GP; immunisations were available for allchildren. There were also antenatal clinics. Last year’s performancefor immunisations was above the averages for the Clinical


Summary of findings


Commissioning Group (CCG). For example, infant meningococcal C(Men C) vaccination rates for two year old children were 97.3%compared to 97.2% across the CCG; and for five year old childrenwere 100% compared to 97.9% across the CCG.

The practice had recently participated in ‘Dr Spike’s Fun Day’, ahealth awareness promotion day for parents of young childrenwhich was held at the local Surestart Centre (centres which provideaccess to a range of early childhood services). The GP registrar andtwo reception staff took part in this day. Feedback was taken fromthe parents and the practice assisted in designing a leaflet forparents on services available to them from primary and secondarycare.

Working age people (including those recently retired andstudents)The practice is rated as requires improvement for the care ofworking-age people (including those recently retired and students).There are aspects of the practice that require improvement andtherefore this impacts on all population groups. The needs of theworking age population (including those recently retired andstudents) had been identified and the practice had adjusted theservices they offered to ensure these were accessible, flexible andoffered continuity of care. The practice found telephoneconsultations worked very well for the working age population.There was on-line access available to book appointments and orderrepeat prescriptions. There was a text and reminder messagingservice. Patients over the age of 45 were offered a blood pressuremonitoring check, the target of 92% was achieved.


People whose circumstances may make them vulnerableThe practice is rated as requires improvement for the care of peoplewhose circumstances may make them vulnerable. There are aspectsof the practice that require improvement and therefore this impactson all population groups. The practice worked withmulti-disciplinary teams in the case management of vulnerablepeople. The practice had sign-posted vulnerable patients to varioussupport groups and organisations. Staff we spoke with knew how torecognise signs of abuse in vulnerable adults and children. Thepractice maintained a register for patients with a learning disability;there were 17 patients on the register of which 82% (14) hadreceived an annual health check. The practice had joint workingwith services for patients with drug and alcohol addiction. They alsosignposted patients to support organisations such as Turning Point.The practice’s computer system alerted GPs if a patient was also acarer. We were shown the written information available for carers toensure they understood the various avenues of support available tothem.


Summary of findings


People experiencing poor mental health (including peoplewith dementia)The practice is rated as requires improvement for the care of peopleexperiencing poor mental health (including people with dementia).There are aspects of the practice that require improvement andtherefore this impacts on all population groups. There was a registerfor those experiencing poor mental health. Referrals for supportwere available with MIND and other services who could offersupport.

If dementia was suspected referrals were made to the local memoryclinic. Staff at the practice had received dementia friends trainingand a member of staff had been identified as a dementia championand was to receive training for this.


Summary of findings


What people who use the service sayWe spoke with nine patients during the inspection,including two members of the Patient ParticipationGroup (PPG). All of the patients we spoke with gave uspositive feedback about the practice. Words usedincluded brilliant and very good. Patients described thestaff as friendly, lovely and helpful. Most patients saidthey could obtain an appointment easily.

We reviewed 27 CQC comment cards completed bypatients prior to the inspection. Comments wereoverwhelmingly positive. Patients praised the care theyreceived, words used included excellent and caring.Comments included positive feedback about the staffwho they found to be helpful, friendly and caring. Severalcomments included how clean they thought the surgerywas. There were four comment cards with negativecomments although all four praised the service theyreceived. Two commented that they found it difficult toget to see a doctor and two were unhappy with thesystem of telephone consultations.

The latest GP Patient Survey published in January 2015showed the majority of patients were satisfied with theservices the practice offered. The majority of patientswho responded described their overall experience asgood. (88% compared to a national average of 79%)

The three responses to questions where the practiceperformed the best when compared to other localpractices were:

1. 92% of respondents usually wait 15 minutes or lessafter their appointment time to be seen (Local clinicalcommisioning group(CCG) average: 70%)

• 70% of respondents with a preferred GP usually get tosee or speak to that GP (Local (CCG) average: 62%)

• 97% of respondents say the last nurse they saw orspoke to was good at involving them in decisionsabout their care (Local (CCG) average: 89%)

The three responses to questions where the practiceperformed least well when compared to other localpractices were:

• 70% of respondents describe their experience ofmaking an appointment as good (Local (CCG) average:77%)

• 90% of respondents say the last appointment they gotwas convenient (Local (CCG) average: 93%)

• 84% of respondents were able to get an appointmentto see or speak to someone the last time they tried(Local (CCG) average: 85%)

These results were based on 120 surveys that werereturned from a total of 341 sent out; a response rate of35%.

The practice carried out its own survey in March 2015. Thepurpose of this was to review patient satisfaction inrelation to the telephone consultation system, which hadbeen introduced recently. 101 patients responded to 150surveys which were sent out, a response rate of 67.3%.

From this survey 82% of patients said they were satisfiedwith the overall service from the practice. Responses tothe questions regarding the telephone system were;

• Patients aware of the telephone consultation system -99%

• Patients who find it easy to get through to the surgeryby telephone - 75%

• Patients who like the telephone consultation system -41%

Areas for improvementAction the service MUST take to improve

• Ensure systems and processes are established andoperated effectively in order to assess, monitor andimprove the quality of service provided in carrying outthe regulated activities.

• Ensure staff receive appropriate training and appraisalin order to carry out the duties they perform.

• Ensure recruitment procedures are established andthat they operate effectively.

Summary of findings


Action the service SHOULD take to improve

• Take steps to monitor equipment to ensure it is in dateand suitable for use.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.The team included a GP specialist advisor, and aspecialist advisor with experience of GP practicemanagement.

Background to Dr Dixit'sPractice (also known as DrDixit & Dr Kolla)The area covered by Dr Dixit’s Practice is primarily thepostcode areas of NE37 and NE38 although some areas ofDH4 (Mount Pleasant and Biddick Woods) and NE9(Springwell Village) are covered. The practice providesservices from one location, The Galleries Health Centre,Washington, Tyne and Wear, NE38 7NQ.

The Galleries Health Centre is a purpose built premises. DrDixit’s Practice is one of four practices in the health centre.The facility is part of the Galleries shopping complex andthe reception area is shared with the local library on thefirst floor, there is a ramp for easy access. A lift is availableto take patients to street level at the rear of the premises,there are two disabled parking bays shared with the otherthree practices.

The practice has two GPs partners, both are male. Thepractice is a training practice and at the time of our

inspection there was a female GP registrar working at thepractice. There is a practice nurse and one health careassistant. There is a practice manager and six receptionand administrative staff.

The practice provides services to approximately 4,900patients of all ages. The practice is commissioned toprovide services within a General Medical Services (GMS)contract with NHS England.

The practice is open between 8.30am and 6pm Monday toFriday.

The service for patients requiring urgent medical attentionout of hours is through the NHS 111 service and Primecare(Primary Care Sunderland) Sunderland.

Why we carried out thisinspectionWe inspected this service as part of our comprehensiveinspection programme.

We carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. This inspection wasplanned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

DrDr Dixit'Dixit'ss PrPracticacticee (also(alsoknownknown asas DrDr DixitDixit && DrDr Kolla)Kolla)Detailed findings


How we carried out thisinspectionTo get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services are provided forspecific groups of people and what good care looks like forthem. The population groups are:

• Older people• People with long-term conditions• Families, children and young people

• Working age people (including those recently retiredand students)

• People whose circumstances may make themvulnerable

• People experiencing poor mental health (includingpeople with dementia)

Before visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. This included the local ClinicalCommissioning Group (CCG) and NHS England.

We carried out an announced visit on 28 April 2015. Duringour visit we spoke with a range of staff. This included GPs,the practice manager, healthcare assistant and receptionand administrative staff. We also spoke with nine patients.We reviewed 27 CQC comment cards where patients andmembers of the public shared their views and experiencesof the service.

Detailed findings


Our findingsSafe track record

As part of our planning we looked at a range of informationavailable about the practice from the National GP patientsurvey and the Quality Outcomes Framework (QOF), whichis a national performance measurement tool. The latestinformation available to us indicated there were no areas ofrisk in relation to patient safety. On the day of theinspection the practice were unable to demonstrate theyhad a safe track record.

We saw mechanisms were in place to report and recordsafety incidents, including concerns and near misses,although they were not always followed. Systems andprocesses to address safety risks such as fire were not fullyembedded enough to ensure patients were kept safe, forexample, staff had not received health and safety or firesafety training. The practice could therefore notdemonstrate a consistent safe track record over the longterm.

Learning and improvement from safety incidentsThe practice manager and GP partners told us there was asystem in place for reporting, recording and monitoringsignificant events, incidents and accidents. The practicemanager and GPs told us that significant events werediscussed as soon as practicable at either monthly clinicalgovernance meetings or monthly staff meetings. Whereincidents and events met the threshold criteria, these werealso added to the local CCG Safeguard Incident & RiskManagement System (SIRMS). We saw a log of significantevents in the last twelve months, there were seven eventsrecorded.

The practice manager explained there was a form for staffto complete regarding to document significant events. Thisform was not always completed. They gave us an exampleof where staff raised concerns regarding the behaviour of apatient which was discussed at a staff meeting and a zerotolerance letter was sent out. The form to document thiswas not completed and therefore learning from this wouldnot be captured with other incidents. Most staff we spokewith were unclear about the significant event process andnot fully aware of what it was or the reasons for it.

National patient safety alerts came to the practice via thepractice manager and some went to the GPs own emailaddresses. The practice manager had responsibility to

disseminate the alerts they received to the mostappropriate member of staff. The practice manager wouldthen ensure the appropriate staff read them as they wereforwarded on the practice computer system. However, thepractice manager said they had identified that this was anarea they could improve in terms of documentation. Theydid not have overall control over the safety alerts whichwent to the GPs and they could not be sure that all GPs sawthe alerts which they needed to. The practice managerexplained they were soon to have a new document systemintroduced into the practice as part of their computersystem which they hoped would improve this process.

Reliable safety systems and processes includingsafeguarding

The practice had systems to manage and review risks tovulnerable children, young people and adults.Safeguarding issues were discussed at the monthlymulti-disciplinary meeting on the second Tuesday of eachmonth. They were attended by the health visitor and socialworker, the school nurses were to be invited in theforthcoming month. The practice had a dedicated GPappointed as the lead for both safeguarding vulnerableadults and children. The GP told us and we saw from stafffiles that the practice nurse and health care assistant hadbeen trained to level 3 for safeguarding children.

Staff training records showed that all staff had receivedsafeguarding children training appropriate to their role.However some staff had not received safeguarding adultstraining. Staff we spoke with were aware of theirresponsibilities regarding information sharing,documentation of safeguarding concerns and how tocontact the relevant agencies in and out of hours. Therewere safeguarding flowcharts for staff to follow in allclinical rooms and in reception.

A notice was displayed in the patient waiting areas toinform patients of their right to request a chaperone. Thepractice had a chaperone policy which had been reviewedin September 2014, however this policy did not set out theneed for non-clinical staff who acted as chaperone to havehad a disclosure and barring (DBS) criminal record check.Staff and the practice manager told us that usually thepractice nurse acted as chaperone; however somenon-clinical staff had been trained to carry out this role andwere occasionally used. Staff we spoke with were aware ofthe requirements for the role of chaperone. However, staff

Are services safe?



including the practice nurse had not received a DBS check.The practice manager assured us that the process to haveDBS checks carried out on staff was to start after ourinspection.

Medicines managementWe checked medicines stored in the treatment rooms andmedicine refrigerators and found all medicines were storedsecurely and were only accessible to authorised staff. Therewas a policy for ensuring that medicines were kept at therequired temperatures, this described the action to take inthe event of a potential failure. Stock control of medicineswas managed by the practice nurse.

Processes were in place to check medicines were withintheir expiry date and suitable for use. All the medicines wechecked were within their expiry dates. Expired andunwanted medicines were disposed of in line with wasteregulations. Blank prescription forms were handledaccording to national guidelines and were kept securely.

There was a protocol for repeat prescribing which was inline with national guidance and was followed in practice.The protocol complied with the legal framework andcovered all required areas. We saw an example of theprocess that was followed when a patient’s medication hadbeen changed following a visit to hospital. This helped toensure that patient’s repeat prescriptions were stillappropriate and necessary.

Cleanliness and infection controlWe saw the practice was clean and tidy. Patients we spokewith told us they were happy with the cleanliness of thefacilities. Comments from patients who completed CQCcomment cards reflected this.

The practice had an infection control policy in place tomonitor the prevention and control of infection. Thepractice nurse was the infection control lead and we saw intheir training file they had received infection control linkpractitioner training in March 2015. However, the practicehad not carried out an infection control audit. There wasno explanation given as to why this had not happened.

The risk of the spread of inspection was reduced as allinstruments used to examine or treat patients were singleuse, and personal protective equipment (PPE) such asaprons and gloves were available for staff to use. Thetreatment room had walls and flooring that was easy toclean. Hand washing instructions were displayed by handbasins and there was a supply of liquid soap and paper

hand towels. The privacy curtains in the consultationrooms were disposable and had the date written on themwhen they were last changed. There were arrangements inplace for the safe disposal of clinical waste and sharps,such as needles and blades.

The surgery was cleaned by NHS property company. Wesaw there were schedules of what the cleaner needed toclean and how often. The practice manager made regularchecks to ensure these were being followed.

We asked about legionella (bacteria found in theenvironment which can contaminate water systems inbuildings) risk assessment. We were told that NHS propertyservices were responsible for this assessment and they didnot provide copies to the practice. The practice managercontacted them prior to our visit and they confirmed that alegionella risk assessment was carried out at the healthcentre every two years.

EquipmentWe looked at the stickers on electrical equipment to seewhen the last portable appliance testing (PAT) had beencarried out. This was variable. The computers had stickerson them which indicated they had been tested in August2014; however other electrical equipment such as the ECGmachine did not seem to have been tested since November2013. We brought this to the attention of the practicemanager who said it was NHS estates who carried out hisfunction and she thought it was up to date and wouldchase this up.

We looked at the stickers on the medical devices whichneeded to be calibrated such as blood pressure monitoringmachines and weighing scales. We saw the last testing datewas November 2013.The practice manager said this hadbeen overlooked .They showed us the last certificate whichwas November 2013. The company who carried out thisservice were due to come and carry out testing theThursday following our inspection.

Staffing and recruitmentWe asked to see the practice’s recruitment policy. However,the practice did not have a recruitment policy. The practicemanager gave us a copy of the staff handbook which weexplained did not set out the expectations, legislation andrequirements for the recruitment of staff.

We looked at a sample of four staff files, of which, two ofthe staff members had been recruited in the last two years.There were no interview notes in any of the files. Each

Are services safe?



member of staff had produced evidence of identity. In thecase of the two most recent members of staff one referencehad been taken up with the previous employer. Thepractice nurse, health care assistant or administration staffhad not received a DBS check whilst working at thepractice. The practice manager assured us that DBS checkswere to be applied for after our visit.

Checks of clinical staff’s professional registration, such asGeneral Medical council (GMC) were carried out on a yearlybasis and held on a spreadsheet. We also saw evidence ofmedical indemnity insurance for all clinicians employed atthe practice.

The practice manager told us it was relatively easy to planand monitor the number of staff and mix of staff needed tomeet patients’ needs due to the practice being small. Thepractice manager received support from another practicein the building if there were sickness issues. If locums wereused the practice vetted the locums themselves and wewere shown an example of a locum’s file.

Monitoring safety and responding to riskThe premises was owned and maintained by NHS propertyservices. The practice manager told us this worked well andthe premises was adequately maintained. However,because of this we had problems accessing documentationto confirm some of the arrangements. We were told thatthe fire risk assessments were held by NHS propertyservices and the practice did not have a copy. There were

weekly tests of the fire equipment and the last fireevacuation drill was in 2014. Staff were aware of where toassemble in case of a fire. Only one member of staff hadreceived fire training.

There was a health and safety risk assessment for eachroom in the surgery including the reception area. Staff hadnot received health and safety training. The practicemanager was booked to go on health safety training in May2015.

Arrangements to deal with emergencies andmajor incidents

The practice had arrangements in place to manageemergencies. Staff training records showed they had allreceived training in basic life support. Emergencyequipment was available including access to oxygen and adefibrillator (used to attempt to restart a person’s heart inan emergency). Staff we spoke with knew where thisequipment was kept and confirmed they were trained touse it. They also showed us the emergency medicineswhich were available in a secure area of the practice and allstaff knew of their location. Processes were also in place tocheck whether emergency medicines were within theirexpiry date and suitable for use. All the medicines wechecked were in date and fit for use.

A business continuity plan was in place to deal with a rangeof emergencies that may impact on the daily operation ofthe practice. This had been updated regularly andcontained relevant contact details for staff to refer to, forexample who to contact if the heating system failed.

Are services safe?



Our findingsEffective needs assessment

The GPs and nursing staff we spoke with could clearlyoutline the rationale for their treatment approaches. Theywere familiar with current best practice guidance,accessing guidelines from the National Institute for Healthand Care Excellence (NICE). We found from our discussionswith the GPs that staff completed, in line with NICEguidelines, thorough assessments of patients’ needs andthese were reviewed when appropriate.

There were care plans in place for 2% of the practicepopulation with the most complex needs to help avoidunplanned admissions into hospital. This included patientswho were pre-diabetic, diabetic, elderly and those withheart and renal failure. Every admitted medical patient wasreviewed to see if the hospital admission could have beenprevented.

We reviewed the most recent Quality and OutcomesFramework (QOF) results for the practice for the year 2013 /2014. QOF is a voluntary incentive scheme for GP practicesin the UK. The scheme financially rewards practices formanaging some of the most common long term conditionsand for the implementation of preventative measures. Wesaw the practice had achieved a score of 99.5% of thepoints available to them for providing recommendedtreatments for the most commonly found clinicalconditions. This was above both the local ClinicalCommissioning Group (CCG) by 5 percentage points andEngland averages by 6 percentage points.

There were clinical leads for the management of illnessesand long term conditions which were shared between theGPs and practice nurse. One of the GPs led on chronicobstructive pulmonary disease, (COPD), diabetes andmental health. The other led on palliative care and learningdisabilities. There were practice nurse led clinics for COPDand diabetes. There were recall systems in place andpatients were offered an annual health check. We saw thepractice achieved maximum QOF points available to themfor all of the chronic conditions, for example, 100% forCOPD which was above the CCG and England averages by2.9 and 4.8 percentage points. All patients with chronicconditions were offered a pneumococcal and flu vaccine inthe last year and the take up rate was 76.9%.

Patients we spoke with said they felt well supported by theGPs and nursing staff with regards to making choices anddecisions about their care and treatment. This was alsoreflected in most of the comments made by patients whocompleted Care Quality Commission (CQC) commentcards. We saw no evidence of discrimination when makingcare and treatment decisions. Interviews with GPs showedthat the culture in the practice was that patients werereferred on need and that age, sex and race was not takeninto account in this decision-making.

Management, monitoring and improvingoutcomes for people

We reviewed a range of data available to us prior to theinspection relating to health outcomes for patients. Thesedemonstrated that the practice was performing better thanaverage, when compared to other practices in England.QOF data showed the practice achieved maximum pointsfor the management of long term conditions such asasthma, chronic obstructive pulmonary disease (lungdisease) and epilepsy.

The practice had a system in place for completing clinicalaudit cycles. We saw two examples of two cycle clinicalaudits had been carried out in the last year. For example,they included a two-cycle audit by one of the GP registrarsoverseen by the GP clinical trainer. The purpose of theaudit was to assess if the practice was adhering to theguidelines in using an antibiotic used to treat urinary tractinfections. The initial audit identified two of the 14 patients(14%) were prescribed incorrectly and one patient’s (7%)renal function was not checked. The GP registrar presentedtheir findings and emphasised the importance of re-audit.This was carried out and the antibiotic was prescribedincorrectly in one patients (8%) compared to the previousaudit and an improvement seen.

There was a protocol for repeat prescribing which was inline with national guidance. In line with this, staff regularlychecked that patients receiving repeat prescriptions hadbeen reviewed by the GP. They also checked that all routinehealth checks were completed for long-term conditionssuch as diabetes and that the latest prescribing guidancewas being used.

The practice had a palliative care register and had regularinternal as well as multidisciplinary meetings to discuss thecare and support needs of patients and their families.

Are services effective?(for example, treatment is effective)



Effective staffingThe practice manager explained that staff had all receivedbasic life support and child safeguarding trainingappropriate to their role. Some staff had startedinformation governance training and some had receivedsafeguarding vulnerable adults training, we saw this in stafffiles. The practice nurse had received fire safety and healthand safety training at a CCG training session, other staff hadnever received fire or health and safety training. Some staffhad received dementia training as the practice managerprovided us with an attendance sheet for this. We saw inthe practice nurse’s staff file they had received trainingappropriate to their role, for example, cervical smearupdate and infection control link practitioner training. Theyhad also received fire safety and health and safety training.

We asked the practice manager about the appraisal systemfor staff at the practice. The practice manager appraisedthe administration staff; one of the GPs appraised thepractice nurse and the practice manager. However, staffappraisals had last been carried out in April 2013. Thepractice manager said this had been discussed at apractice meeting in 2014 and due to too many changestaking place in the practice they had agreed as a practicethat no appraisal would be undertaken that year. Theywere scheduled to take place in May 2015.

Working with colleagues and other servicesThe practice could demonstrate that they worked withother services to deliver effective care and treatment acrossthe different patient population groups. The practice heldmultidisciplinary team meetings every month. Thisincluded meetings regarding child protection and palliativecare. These meetings were attended by the practice’s GPsand nurse along with district nurses, social workers andpalliative care nurses depending upon the meeting. Wesaw minutes of the meeting held in April 2015.

The practice received a list of unplanned admissions andattendance at accident and emergency (A&E) to supportthem to monitor this area. This helped to share importantinformation about patients including those who were mostvulnerable and high risk.

Blood results, x-ray results, letters from the local hospitalincluding discharge summaries, out-of-hours providers andthe NHS 111 service, were received both electronically andby post.

We found appropriate end of life care arrangements were inplace. The practice maintained a palliative care register. Wesaw there were procedures in place to inform externalorganisations about any patients on a palliative carepathway. This included identifying such patients to thelocal out-of-hours provider and the ambulance service.

Information sharingThe practice used electronic systems to communicate withother providers. Electronic systems were in place formaking referrals, and the practice made referrals throughthe Choose and Book system. (The Choose and Booksystem enables patients to choose which hospital they willbe seen in and to book their own outpatient appointmentsin discussion with their chosen hospital). Staff reportedthat this system was easy to use and patients welcomedthe ability to choose their own appointment dates andtimes.

The practice had systems in place to provide staff with theinformation they needed. An electronic patient record wasused by all staff to co-ordinate, document and managepatients’ care. All staff were fully trained on the system. Thissoftware enabled scanned paper communications, such asthose from hospital, to be saved in the system for futurereference.

Consent to care and treatmentWe found, before patients received any care or treatmentthey were asked for their consent and the practice acted inaccordance with their wishes. Staff we spoke with told usthey ensured they obtained patients’ consent to treatment.Staff were able to give examples of how they obtainedverbal or implied consent.

GPs we spoke with showed they were knowledgeable ofGillick competency assessments of children and youngpeople. Gillick competence is a term used in medical law todecide whether a child (16 years or younger) is able toconsent to his or her own medical treatment, without theneed for parental permission or knowledge.

Decisions about or on behalf of people who lacked mentalcapacity to consent to what was proposed were made inthe person’s best interests and in line with the MentalCapacity Act (MCA). We found the GPs were aware of theMCA and used it appropriately. The GPs described theprocedures they would follow where people lackedcapacity to make an informed decision about theirtreatment. They gave us some examples where patients did




not have capacity to consent. The GPs told us anassessment of the person's capacity would be carried outfirst. If the person was assessed as lacking capacity then a“best interest” discussion needed to be held. They knewthese discussions needed to include people who knew andunderstood the patient, or had legal powers to act on theirbehalf.

Health promotion and preventionNew patients were required to complete a pre-registrationform and a medical questionnaire. All patients were offereda health check and then could be referred to the GP for afurther check dependent upon their medical history.

The practice offered a full range of clinics; these includedcounselling, contraceptive services including familyplanning, cervical smear screening, smoking cessation,travel and flu vaccinations and management of long termconditions. NHS health checks were offered for patientsaged 40 -74. Patients over the age of 45 were offered ablood pressure monitoring check, the target of 92% wasachieved. The practice had an electrocardiogram (ECG)machine and the health care assistant ran ECG clinics.

The QOF data for 2013/14 confirmed the practice obtained100% of the total points available for supporting patients tostop smoking, this was 5.8 percentage points above thelocal CCG average and 6.3 percentage points above theEngland average, using a strategy that included theprovision of suitable information and appropriate therapy.The data also showed the practice had obtained 100% ofthe total points available to them for providing

recommended care and treatment for patients diagnosedwith obesity. This was in line with the local CCG andEngland averages. The practice had also obtained 100% ofthe points available to them for providing cervicalscreening to women from QOF. This was 0.8 percentagepoints above the local CCG average and 2.5 points abovethe England average. The take up of cervical screening inthe last five years for woman aged between 25-64 was81.6% (England average 76.9% and CCG average 78.3%)

The practice offered child health clinics for children underthe age of five in conjunction with the health visitor,practice nurse and a GP; immunisations were available forall children. There were also antenatal clinics. Last year’sperformance for immunisations was above the averages forthe Clinical Commissioning Group (CCG). For example,infant meningococcal C (Men C) vaccination rates for twoyear old children were 97.3% compared to 97.2% across theCCG; and for five year old children were 100% compared to97.9% across the CCG.

The practice had recently participated in ‘Dr Spike’s FunDay’, a health awareness promotion day for parents ofyoung children which was held at the local Surestart Centre(centres which provide access to a range of early childhoodservices). The GP registrar and two reception staff took partin this day. Feedback was taken from the parents and thepractice assisted in designing a leaflet for parents onservices available to them from primary and secondarycare.




Our findingsRespect, dignity, compassion and empathy

We reviewed the most recent data available for the practiceregarding patient satisfaction. This included informationfrom the national GP patient survey. For example, theproportion of patients who described their overallexperience of the GP surgery as good or very good was88%, which was lower than the CCG average of 90%. Theproportion of patients who said their GP was good or verygood at treating them with care and concern was 90%, theCCG average was 86%. The proportion of patients who saidthe nurse was good or very good at treating them with careand concern was 87%, the CCG average was 82%.

In the practice’s own survey of March 2015 patient feedbackincluded;

• Patients said they were satisfied with the overall servicefrom the practice – 82%.

• The GP listened to patients 81%, spent enough timewith the patient – 68% and answered their questions63%.

• The practice nurse listened to patients 97%, spentenough time with the patient – 96% and answered theirquestions 95%.

We reviewed 27 CQC comment cards completed bypatients prior to the inspection. Comments wereoverwhelmingly positive. Patients praised the care theyreceived, words used included excellent and caring.Comments included positive feedback about the staff whothe found to be helpful, friendly and caring.

We spoke with nine patients during the inspection,including two members of the Patient Participation Group(PPG). All of the patients we spoke with gave us positivefeedback about the practice. Words used included brilliantand very good. Patients described the staff as friendly,lovely and helpful.

The practice’s own patient survey gave feedback on thereceptions staff. 98% found them friendly, 92% efficient and88% thought they were able to explain changes.

We observed staff who worked in the reception area andother staff as they received and interacted with patients.Their approach was seen to be considerate, understandingand caring, while remaining respectful and professional.

People's privacy, dignity and right to confidentiality weremaintained. For example, the practice offered a chaperoneservice for patients who wanted to be accompanied duringtheir consultation or examination. There was not a notice inthe reception area which offered patients the opportunityto speak to reception staff in a private room, if necessary.

Staff were aware of the need to keep records secure. Wesaw patient records were mainly computerised andsystems were in place to keep them safe in line with dataprotection legislation.

Care planning and involvement in decisionsabout care and treatment

Patients told us they felt listened to by the GPs and practicenurses. They said the clinical staff gave them plenty of timeto ask questions and responded in a way they couldunderstand. They were satisfied with the level ofinformation they had been given. Patient feedback on thecomment cards we received was also positive and alignedwith these views.

From the 2015 National GP Patient Survey, 85% of patientssaid the GP they visited had been ‘good’ at involving themin decisions about their care (CCG average was 87%). Thedata showed that 97% of patients said the practice nursethey visited had been ‘good’ at involving them in decisionsabout their care (CCG average 89%).

Staff told us that translation services were available forpatients who did not have English as a first language.

Patient/carer support to cope emotionally withcare and treatment

The patients we spoke with on the day of our visit told usstaff responded compassionately when they needed helpand provided support when required. We saw there was avariety of patient information on display throughout thepractice. This included information on health conditions,health promotion and support groups.

The practice’s computer system alerted GPs if a patient wasalso a carer. We were shown the written informationavailable for carers to ensure they understood the variousavenues of support available to them.

There was a palliative care register and regular contact withthe district nurses. There were monthly palliative caremeetings which involved GPs, district nurses and palliativecare nurses.

Are services caring?

Good –––


Staff told us that if families had suffered bereavement, a GPwould contact them. This call was either followed by apatient consultation at a flexible time and location to meet

the family’s needs or by giving them advice on how to find asupport service. One of the CQC comment cards completedpraised the practice for being supportive when they hadreceived two recent bereavements.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

We found the practice was responsive to people’s needsand had systems in place to maintain the level of serviceprovided. The needs of the practice population were takenin to account. The staff at the practice including the GPshad worked at the practice for several years which enabledgood continuity of care.

A practice development plan had been produced in July2014 which set out statements as to what the practicehoped to achieve in the next year, for example, the nasal fluvaccine for children aged 2-4 years old. 66.5% werevaccinated in the last year.

All patients over the age of 75 had a named GP and wereinvited to the practice for an over 75 health check. Patientsover the age of 65 were offered the pneumococcal and fluvaccine and attendance rates for this in the last seasonwere 94%. The health care assistant and practice nursecarried out home visits to patients who were unable toattend the surgery during the winter flu vaccine season andwere able to administer the vaccine if appropriate andcarryout a health check, the opportunity was also taken upto update the patients records with carer or next of kindetails.

The practice had a palliative care register and had monthlymultidisciplinary meetings to discuss patients and theirfamilies’ care and support needs. The practice workedcollaboratively with other agencies and regularly sharedinformation to ensure good, timely communication ofchanges in care and treatment.

The practice had implemented suggestions forimprovements and made changes to the way it deliveredservices as a consequence of feedback from the practicePPG. The group had made suggestions about noticeboardsin the waiting areas and action was taken to improve this.

Tackling inequity and promoting equalityThe practice had recognised the needs of different groupsin the planning of its services. The practice had access totelephone translation services if required, for thosepatients whose first language was not English. The practicehad a member of staff who was fluent in Lithuanian andRussian; some patients came to the practice specificallybecause of this.

The practice maintained a register for patients with alearning disability; there were 17 patients on the register ofwhich 82% (14) had received an annual health check. Therewas a register for those experiencing poor mental health.Referrals for support were available with MIND and otherservices who could offer support.

The practice had joint working with services for patientwith drug and alcohol addiction. They also signpostedpatients to support organisations such as turning point.

If dementia was suspected referrals were made to the localmemory clinic. Staff at the practice had received dementiafriends training and a member of staff had been identifiedas a dementia champion and was to receive training forthis.

The surgery was purpose built. All of the treatment andconsulting rooms could be accessed by those with mobilitydifficulties. There was a ramp at the front of the building foreasy access. A lift was available to take patients to streetlevel at the rear of the premises there were two disabledparking bays shared with the other three practices in thebuilding.

The practice had male and female GPs, which gave patientsthe ability to choose to see a male or female GP.

Access to the serviceMost of the patients we spoke with said they could obtainan appointment easily. From the CQC comment cardscompleted there were four cards with negative comments,although all four praised the service they received, twocommented that they found it difficult to get to see adoctor and two were unhappy with the system oftelephone consultations. The National GP Patient Survey2015 showed patient satisfaction was in line with the localaverages, 81% of patients were very satisfied or fairlysatisfied with the practice opening hours (CCG average82%). 93% thought the practice was open at timesconvenient for them (CCG average 94%).

The responses to the practice’s own survey in March 2015on the telephone system were;

• Patients aware of the telephone consultation system -99%

• Patients who find it easy to get through to the surgery bytelephone - 75%

• Patients who like the telephone consultation system -41%

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


The surgery opening times were between 8.30am and 6pmMonday to Friday. The GPs operated a telephoneconsultation triage system where they would discusstreatment with the patient accordingly or arrange a face toface appointment. Routine appointments could be bookedup to two weeks in advance for the GPs, practice nurse andhealth care assistant. Home visits and telephoneconsultations were also available. The GPs told us that theGP triage system for appointments had not been popularwith patients when it had been introduced but theythought this was the best way forward for the practice intrying to prioritise patients with the most urgent needs andto deliver a service to patients.

Information was available to patients about appointmentson the practice website and in the patient informationleaflet. This included how to arrange urgent appointmentsand home visits. There was a separate leaflet givingdetailed information about on line services. There werealso arrangements to ensure patients received urgentmedical assistance when the practice was closed. Ifpatients called the practice when it was closed, ananswerphone message gave the telephone number theyshould ring depending on the circumstances. Informationon the out-of-hours service was provided to patients. Thepractice offered appointments and repeat prescriptionson-line. Repeat prescriptions could also be ordered via faxor at reception. There was a text and reminder messagingservice for appointments.

Listening and learning from concerns andcomplaints

The practice had a system in place for handling complaintsand concerns. Their complaints policy and procedureswere in line with recognised guidance and contractualobligations for GPs in England. There was a designatedresponsible person who handled all complaints in thepractice.

We saw that information was available to help patientsunderstand the complaints system. There was a leafletcalled ‘Complaints and comments leaflet’ available at thereception area. This gave patients information regardinghow to make a complaint, explained the procedure andother authorities they could involve in their complaint.

The practice manager supplied us with a schedule of fivecomplaints which had been received in the last 12 months.We looked at two and we found these had both been dealtwith in a satisfactory manner.

The practice manager explained complaints were reviewedevery year with the PPG, to establish any patterns or trends.The practice kept a folder of thank you cards with positivefeedback from patients thanking the practice for their care.

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


Our findingsVision and strategy

The practice had a vision to provide a highly patientfocused service with a multidisciplinary approach topatient’s healthcare. They aimed to deliver the best care fortheir patients by combining the skills of the practice teamwith other health and social care workers in thecommunity.

The practice development plan set out the vision for 2014/15 and set out key steps over this period for the practice.This included education, training and development, clinicalgovernance and prescribing. However, there were noreview dates set to monitor progress in the areas identified.There were business meetings held monthly and yearlypractice development meetings with the GP partners andpractice manager.

The practice told us they had identified the challenges theyfaced. This included access to staff training, protected time,managing information and patient access and satisfaction.They explained that they were trying to educate thepatients in relation to access as they were aware that theGP triage system was not always popular with patients.They were in the process of developing an IT system for thepractice on which they could place policies and proceduresfor the staff to access easily.

The practice were one of five GP practices in the local areawho were looking to work collaboratively by forming afederation to provide healthcare services to thecommunity. One of the areas which they were hoping thefederation would help them with was access to training.

Governance arrangementsThe governance arrangements did not always operateeffectively. There were some policies and procedures inplace, however there were risks to the health and safety ofpatients and staff which had not been assessed. Forexample, there was no infection control audit. Someclinical staff had not received DBS checks. The testing ofmedical equipment was not up to date. Staff told us theyknew where policies and procedures were kept on thepractice’s shared computer drive and they knew how toaccess them.

The practice had a system in place for clinical audit. Thepractice used the Quality and Outcomes Framework (QOF)as an aid to measure their performance. The practice had

achieved a score of 99.5% of the points available to themfor providing recommended treatments for the mostcommonly found clinical conditions. This was above boththe local Clinical Commissioning Group (CCG) by 5percentage points and England averages by 6 percentagepoints. We saw the practice achieved maximum pointsavailable to them for all of the chronic conditions, forexample, 100% for COPD which was above the CCG andEngland averages by 2.9 and 4.8 percentage points. Therewere clinical leads for the management of illnesses andlong term conditions which were shared between the GPsand practice nurse.

Leadership, openness and transparencyThere was a well-established management team with clearallocation of responsibilities. For example, one of the GPpartners was the lead for diabetes. Staff we spoke withwere all clear about their own roles and responsibilities.They all told us they felt valued, well supported and knewwho to go to in the practice with any concerns.

Regular meetings, involving staff at all levels, were held.The practice manager showed us examples of minutes ofthe meetings which were held, for example,multi-disciplinary (MDT) and clinical meetings.

We found the practice learned from incidents and nearmisses. Significant events meetings were held where suchissues were discussed. However, the practice couldimprove awareness of significant events for staff and theprocedures for the reporting of incidents could also beimproved.

Practice seeks and acts on feedback from itspatients, the public and staff

The practice had gathered feedback from patients throughpatient surveys, comments and complaints received.

The practice had a patient participation group (PPG) since2005; however there were only four members. The practicewere trying to recruit new members. We saw the minutes ofthe last PPG meeting which was held in March 2015.Significant events, an annual review of complaints and thetelephone consultation system were discussed. There wasa copy of the last patient survey carried out in March 2015available on the practice website.

NHS England guidance states that from 1 December 2014,all GP practices must implement the NHS Friends andFamily Test (FFT). (The FFT is a tool that supports thefundamental principle that people who use NHS services

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



should have the opportunity to provide feedback on theirexperience that can be used to improve services. It is acontinuous feedback loop between patients and practices).We saw the practice had recently introduced the FFT. Therewere questionnaires available at the reception desk andinstructions for patients on how to give feedback. Thepractice manager told us the comments and feedbackwould be reviewed regularly.

The practice gathered feedback from staff through staffmeetings. Staff we spoke with told us they regularlyattended staff meetings. They said these provided themwith the opportunity to discuss the service being delivered,feedback from patients and raise any concerns they had.However, there had been no staff appraisals carried outsince April 2013. The practice manager said this had beendiscussed at a practice meeting and due to too manychanges taking place in the practice they had agreed as apractice that no appraisal would be undertaken in 2014.

The practice had a whistle blowing policy which wasavailable to all staff electronically on any computer withinthe practice. Staff we spoke with were aware of the policy,how to access it and said they would not hesitate to raiseany concerns they had.

Management lead through learning andimprovement

The practice had some management systems in placewhich enabled learning and improved performance.

Although we found that staff had not received somemandatory training they felt they were supported in thisarea and attended the monthly CCG protected learningtime (PLT) initiative. This provided the team with dedicatedtime for learning and development.

The management team met weekly to discuss anysignificant incidents that had occurred. Reviews ofsignificant events and other incidents had been completedand shared with staff. Staff meeting minutes showed theseevents and any actions taken to reduce the risk of themhappening again were discussed.

GPs met with colleagues at CCG meetings. They alsoattended learning events and shared information fromthese with the other GPs in the practice. The practicemanager met with other practice managers from the CCGarea.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

How the regulation was not being met: Systems andprocesses were not established and operated effectivelyin order to assess, monitor and improve the quality ofservice provided in carrying out the regulated activities.

Risks were not effectively assessed, monitored andmitigated in relation to the health, safety and welfare ofpatients and staff.

Regulation 17 Health & Social Care Act 2008 (RegulatedActivities) Regulations 2014 Good governance. (1), (2) (a)(b)





Regulation 18 HSCA (RA) Regulations 2014 Staffing

How the regulation was not being met:

Staff did not receive appropriate training nor did theyreceive appraisal which is necessary to carry out theduties they perform.

Regulation 18 Health & Social Care Act 2008 (RegulatedActivities) Regulations 2014 Staffing (2) (a)





Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

How the regulation was not being met: The registeredperson must ensure that person’s employed for carryingout the regulated activity are of good character.

Recruitment procedures must be established andoperated effectively.

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


Regulation 19 Health & Social Care Act 2008 (RegulatedActivities) Regulations 2014 Fit and proper personsemployed. (1) (a), (2) (a) (b)

This section is primarily information for the provider

Requirement notices


Documents

Dr Dixit's Practice NewApproachComprehensive …...17 Dr Dixit's Practice (also known as Dr Dixit & Dr Kolla) Quality Report 09/07/2015 nothavecapacitytoconsent.TheGPstoldusan assessmentoftheperson'scapacitywouldbecarriedout