Dr Javier Oscar Salerno Scheduled Report ... · Importantly,theprovidermust:...

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 Good –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

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

Are services well-led? Good –––

DrDr JavierJavier OscOscarar SalernoSalernoQuality Report

Parkway Health CentreParkway, New AddingtonCroydonSurreyCR0 0JATel: 01689849993Website:www.drsalernospractice.co.uk

Date of inspection visit: 6 October 2014Date of publication: 22/01/2015

1 Dr Javier Oscar Salerno Quality Report 22/01/2015

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 10

Background to Dr Javier Oscar Salerno 10

Why we carried out this inspection 10

How we carried out this inspection 11

Detailed findings 12

Action we have told the provider to take 24

Overall summaryLetter from the Chief Inspector of GeneralPractice

Dr Javier Oscar Salerno is a small GP practice based inCroydon. The practice provides primary care services to3,300 patients. We carried out an announcedcomprehensive inspection on 06 October 2014.

During this inspection we inspected the Parkway HealthCentre, which is a satellite location. The practice has abranch surgery; Gravel Hill Surgery which was notinspected.

Key Findings;

Overall the practice is rated as good. Howeverimprovements are required for safe because receptionstaff acting as chaperones did not have Disclosure andBarring Service (DBS) checks. However risks to patientswere assessed and well managed and there were enoughstaff to keep people safe.

The practice used evidence based care with reference toguidance from organisations such as National Institutefor Health and Care Excellence (NICE). Patients’ needswere assessed and care was planned and delivered inline with current legislation.

The practice provided support to its patients duringperiods of bereavement. Patients said they were treatedwith compassion, dignity and respect and they wereinvolved in care and treatment decisions. The practicehad a Patient Participation Group (PPG).The PPGmembers told us that the practice worked closely withthem and their views were taken on board.

The practice reviewed the needs of their local populationand engaged with the local Clinical CommissioningGroup (CCG) to secure service improvements where thesewere identified.

We found that the practice had a clear vision and strategyto deliver care. Staff were clear about the vision and theirresponsibilities in relation to this. There was a clearleadership structure and staff felt supported bymanagement.

Summary of findings


Importantly, the provider must:

Ensure that reception staff acting as chaperones havecurrent Disclosure and Barring Checks (DBS) Reg 21.

Action the provider should take to improve:

Introduce online appointments booking system to enablepatients to request appointments flexibly.

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 safe becausereception staff acting as chaperones did not have Disclosure andBarring Service (DBS) checks. However staff understood and fulfilledtheir responsibilities to raise concerns, and report incidents andnear misses. Lessons were learned and communicated widely tosupport improvement. Information about safety was recorded,monitored, appropriately reviewed and addressed. Risks to patientswere assessed and well managed. There were enough staff to keeppeople safe.

Requires improvement –––

Are services effective?The practice is rated as good for effective. Data showed patientoutcomes were at or above average for the locality. The Practice hadcompleted an audit to ensure patients with dementia were receivingyearly checks that assessed physical as well as social needs. Thepractice found that 100% of their patients had been offered a reviewwith a discussion on their social support and needs having takenplace. A further audit had identified four patients that had beenmissed from the chronic disease register and were not havingsuitable medicines. Following the audit, these patients were addedto the register and their care was been planned accordingly. Thepractice used evidence based care with reference to guidance fromorganisations such as National Institute for Health and CareExcellence (NICE). Patients’ needs were assessed and care wasplanned and delivered in line with current legislation. This includedassessment of capacity and the promotion of good health. Staff hadreceived training appropriate for their roles and further trainingneeds had been identified and planned.

Good –––

Are services caring?The practice is rated as good for caring. Patients said they weretreated with compassion, dignity and respect and they wereinvolved in care and treatment decisions. Accessible informationwas provided to help patients understand the care available tothem. We also saw that staff treated patients with kindness andrespect ensuring confidentiality was maintained.

Good –––

Are services responsive to people’s needs?The practice is rated as good for responsive. The practice reviewedthe needs of their local population and engaged with the localClinical Commissioning Group (CCG) to secure serviceimprovements where these were identified. Patients reported goodaccess to the practice and a named GP and continuity of care, with

Good –––

Summary of findings


urgent appointments available the same day. The practice had goodfacilities and was well equipped to treat patients and meet theirneeds. There was an accessible complaints system with evidencedemonstrating that the practice responded quickly to issues raised.There was evidence of shared learning from complaints with staffand other stakeholders.

Are services well-led?The practice is rated as good for well-led. The practice had a clearvision and strategy to deliver care. Staff were clear about the visionand their responsibilities in relation to this. There was a clearleadership structure and staff felt supported by management. Thepractice had a number of policies and procedures to govern activityand regular governance meetings had taken place. There weresystems in place to monitor and improve quality and identify risk.The practice proactively sought feedback from staff and patientsand this had been acted upon. The practice had an active PatientParticipation Group (PPG). Staff had received inductions, regularperformance reviews and attended staff meetings.

Good –––

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 good for the care of older people.

All patients aged 75 and over had a named GP. Patients wereoffered an annual health check offered at the practice or at home forthose patients that could not travel to the practice. This assessmentassessed physical health, mobility, nutrition needs and social needs.The practice had a named social worker they worked closely withand made referrals to.

The GPs visited a local nursing home and were involved in careplanning of those patients. The practice also had a local hospicecentre attached to them. The care of these patients was plannedwith the local palliative team. The practice arranged and heldmeetings with the district nurses, the end of life care team and thehospice on a regular basis.

Good –––

People with long term conditionsThe practice is rated as good for the population group of peoplewith long term conditions.

The practice offered patients diagnosed with conditions such asdiabetes, epilepsy, coronary heart disease and chronic obstructivepulmonary disease on going care monitoring and the name of theirnamed professional as a first point of contact. These patients wereoffered annual flu vaccination as per national guidance andreminders were sent for those who had still not attended includinghome visits.

The nurses offered disease management reviews. The nursesreferred patients to the GPs if change of medicines was required.

Asthmatic patients had regular reviews which included checks toensure they were using their nebulisers according to instructions.Diabetes patients were offered a foot assessment and referral tospecialist services.

Good –––

Families, children and young peopleThe practice is rated as good for the population group of families,children and young people. The practice had a policy to offer sameday appointments to children aged 0-12months.They held weeklychild health clinics. This clinic was run by the GPs with the nurse.Women were offered six weeks post-natal checks and the practice

Good –––

Summary of findings


worked closely with local maternity services and midwives. The GPsexamined babies at eight weeks and vaccinated them at eightweeks. The nurses continued the childhood vaccinationprogramme.

The practice held meetings with the local safeguarding teams.However the GPs told us that accessing the Health visiting servicesin Croydon was difficult. There had been numerous changes toservice delivery and as such they no longer had a named healthvisitor. They told us that this had been feedback to the local ClinicalCommissioning Group.

Weekly family planning clinics and Sexually Transmitted Diseaseadvice was also offered to young people and teenage mothers.

Working age people (including those recently retired andstudents)The practice is rated as good for the population group of theworking-age people (including those recently retired andstudents).Late evening appointments were available for workingpatients twice a week.

Patients aged 40 -74 years were offered health checks in accordanceto local and national guidance. The practice offered Well Man andWell Woman checks with the nurse. This was an opportunity todiscuss any aspect of general health such as dietary problems,stress, alcohol consumption, smoking and all aspects of women`shealth; including breast examination, the menopause, cervicalsmears and contraception.

Good –––

People whose circumstances may make them vulnerableThe practice is rated as good for the population group of peoplewhose circumstances may make them vulnerable. The practiceoperated a “red flag” system for patients in vulnerablecircumstances. The purposes of this was to identify these patientson the record system to ensure none of their care needs were notfollowed up on. The practice had a small number of patients withlearning disabilities. The practice had carried out annual healthchecks for people with learning disabilities and 100 % of thesepatients had received a follow-up. The check also covered generalhealth, social environment, medication review, mood and lifestyle.

The practice registered patients from the travelling communities.Services were planned according to need recognising that patientswould move frequently and as such opportunistic appointmentswere available. Screening services such as smear testing, bloodpressure monitoring and smoking cessation advice was offered.

Good –––

Summary of findings


The practice had produced a leaflet they named, “the helping hand”.It contained sign posting information to patients at risk of abuse orin other vulnerable circumstances on services that were availablelocally in Croydon offering support.

Staff at the practice told us they would offer services tailored for thehomeless but they did not have any patients registered as homeless.

People experiencing poor mental health (including peoplewith dementia)

The practice is rated as good for the population group of peopleexperiencing poor mental health (including people with dementia).98.2% of people experiencing poor mental health had received anannual physical health check. While 100% of patients with dementiahad received yearly checks. The practice maintained a register ofpatients experiencing poor mental health. These patients werereviewed on a regular basis and had a named GP.

Reviews involved medication, general health, and psychiatricassessment. The practice made appropriate referrals to thecommunity psychiatric team. Leaflets were available on localservices that patients could self-refer to such as “Mind”. However theGPs told us that the care delivered to patients with mental healthconditions in Croydon needed improvement because services wereundergoing review and as such did not always offer care that wascollaborated with other organisations such as GPs.The practiceoffered patients normal general practice services such as smeartesting, breast screening and advice on prostate cancer symptoms.

Good –––

Summary of findings


What people who use the service sayWe spoke with six patients during our inspection andreceived 10 completed comments cards.

Patients reported being happy with the care andtreatment they received. All patients we spoke with werecomplimentary on the attitudes of all staff and reportedfeeling “well cared for” and respected.

Patients reported being happy with the appointmentssystem which they felt suited their needs

We looked at patient feedback from the NHS choiceswebsite in the year before our inspection. Two out of

three patients described their experience of using thepractice as “good”. They described the process requestingappointments as good and felt that their needs were welllooked after. However, one patient felt that the GPs at thepractice were always late and never apologised.

We spoke with three representatives from the PatientParticipation Group (PPG). Although they had not yetcompleted a survey they reported no concerns with thepractice. They told us that the practice welcomedcomments and suggestions from them.

Areas for improvementAction the service MUST take to improveEnsure that all staff acting as chaperones have Disclosureand Barring (DBS) checks.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspectorand a GP specialist adviser.

You should also be aware that experts who take part inthe inspections, for example, Experts by Experience, arenot independent individuals who accompany aninspection team – they are a part of the inspection teamand should be described in that way. They are grantedthe same authority to enter registered persons’premises as the CQC inspectors.

Background to Dr Javier OscarSalernoDr Javier Salerno is a small GP practice based inCroydon.The practice provides primary care services to3,300 patients. The ethnicity of patients is mainly whiteBritish with a small mixed number of Asian and BlackCaribbean patients.

In Croydon male life expectancy is 78.9 years and femalelife expectancy is 82.2 years. Both are above the Englandaverage for both males and females. Death rates from allcauses are falling at approximately the same pace acrossthe borough. However, there has been little change in thegap in life expectancy between the most deprived areasand the least deprived areas between 1995 and 2008. Themain causes of death in Croydon are circulatory diseases,cancers and respiratory diseases.

The early death rate from all cancers in those under 75years old is below the London and

England averages. However, those in the most deprivedareas of Croydon have a much higher rate of death from allcancers than those living in the least deprived areas.

The practice is located in a shared communal health centrewith other practices. During this inspection we visited theParkway Health Centre. The practice is a satellite location.The branch practice was not visited as it is a separatelocation and has a separate patient list to the ParkwayHealth Centre.

The practice has a full time principal male GP and one parttime salaried female GP who is employed for a total of foursessions per week. The practice has four reception staff,one health care assistant and a practice nurse providing 16hours per week.

The practice holds a Personal Medical Services (PMS)contract for the delivery of general medical service.Personal Medical Services (PMS) agreements are locallyagreed contracts between NHS England and a GP practice.PMS contracts offer local flexibility compared to thenationally negotiated General Medical Services (GMS)contracts by offering variation in the range of serviceswhich may be provided by the practice, the financialarrangements for those services and the provider structure(who can hold a contract).

The practice have opted out of providing out-of-hoursservices to their own patients. A local out of hoursservice,111 is used to cover emergencies.

Why we carried out thisinspectionWe 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 legal

DrDr JavierJavier OscOscarar SalernoSalernoDetailed findings


requirements 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.

This provider had not been inspected before and that waswhy we included them.

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

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 retired

and students)• People living in vulnerable circumstances• People experiencing poor mental health (including

people with dementia)

Before visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on 6October 2014. During our visit we spoke with a range ofstaff such as GPs, practice manager, practice nurse andadministrative staff, and spoke with patients who used theservice. We observed how people were being cared for andtalked with carers and/or family members. We received 10completed patient comments cards.

Detailed findings


Our findingsSafe Track RecordThe practice used a range of information to identify risksand improve quality in relation to patient safety. A log bookwas used to record all incidents. Staff we spoke with wereaware of their responsibilities to raise concerns, and how toreport incidents and near misses. For example an error hadoccurred when an administrative staff had entered thewrong patient information. A patient had been added toone of the chronic disease registers by mistake. Theadministrative staff on recognising this mistake recorded itand notified the practice manager. This error was rectifiedand improvements were made to the system used toregister patients with a chronic disease.

We reviewed safety records, incident reports and minutesof meetings for the last two years. These demonstrated thatsafety issues and incidents were discussed and the practicehad managed these consistently over time.

Learning and improvement from safety incidentsThe practice had a system in place for reporting, recordingand monitoring significant events, incidents and accidents.Records were kept of significant events that had occurredduring the last two years and these were made available tous. A slot for significant events was on the practice meetingagenda and a dedicated meeting occurred once a monthto review actions from past significant events andcomplaints. There was evidence that appropriate learninghad taken place and that the findings were disseminated torelevant staff. Staff including receptionists, administratorsand nursing staff were aware of the system for raisingissues to be considered at the meetings and feltencouraged to do so. All staff told us that incidents werereported to the practice manager as soon as possible and awritten account of the incident was recorded in the logbook. Examples of incidents included patient details beingentered incorrectly. This had resulted in a misseddiagnosis. We saw that this incident had been discussedwith all staff .The process of entering patient details wasthen improved with a second staff member verifying allentries to ensure they were correct.

National patient safety alerts were disseminated by thepractice manager to practice staff. Staff we spoke with wereable to give examples of recent alerts relevant to the carethey were responsible for. For example, nurses responsiblefor administering vaccines told us about recent alerts

relating to changes in childhood vaccines schedules. Wesaw records confirming alerts were circulated to all relevantstaff using email. In addition, copies were kept on files forfuture use and to provide an audit trail.

Reliable safety systems and processes includingsafeguarding

The practice had systems to manage and review risks tovulnerable children, young people and adults. The practicehad a dedicated GP appointed as lead for safeguardingvulnerable adults and children who had been trained andcould demonstrate they had the necessary skills to enablethem to fulfil this role. Arrangements were also available forcover during the absence of the lead GP to ensure staff hada responsible nominated person to contact.

All staff we spoke with were aware of who the lead personwas and who to speak to in the practice if they had asafeguarding concern. For example, staff told us about ascenario where they were worried that an elderly patientwas being financially abused. They reported this to the leadGP who referred the case to social services.

Training records showed that all staff had received relevantrole specific training in safeguarding children and adults.All GPs at the practice had received Level 3 child protectiontraining. The practice nurses had received Level 2 childprotection training and reception and administration staffhad all received Level 1 training. Staff knew how torecognise signs of abuse in older people, vulnerable adultsand children. They were also aware of their responsibilitiesregarding information sharing, documentation ofsafeguarding concerns and how to contact the relevantagencies in and out of hours. Contact details of the localsafeguarding teams were easily accessible to staff throughdisplay on notice boards.

The practice used a flagging system to identify all childrenand families who were on protection plans and Lookedafter children (LAC) to ensure they were continuouslyassessed and monitored as required.

The practice sent out safeguarding reports to the localauthority as required when they could not attend strategymeetings or case conferences.

The practice worked closely with a social worker andreferred all safeguarding concerns they had of elderlypatients, those in vulnerable circumstance and patientsexperiencing mental health problems.

Are services safe?



A chaperone policy was in place and on display on thewaiting room noticeboard and in consulting rooms.Chaperone training had been undertaken by all nursingstaff, including health care assistants. All receptionists hadalso undertaken training and understood theirresponsibilities when acting as chaperones includingwhere to stand to be able to observe the examination.However staff who were acting as chaperones had not hadDisclosure and Barring Checks (DBS) or been risk assessedfor carrying out this role.

Patient’s individual records were written and managed in away to help ensure safety. Records were kept on anelectronic system, which collated all communicationsabout the patient including scanned copies ofcommunications from hospitals. GPs were appropriatelyusing the required codes on their electronic casemanagement system to ensure risks to children and youngpeople who were looked after or on child protection planswere clearly flagged and reviewed. The lead GP forsafeguarding was aware of vulnerable children and adultsand demonstrated good liaison with partner agencies suchas the police and social services.

Medicines ManagementWe checked medicines stored in the treatment rooms andmedicine refrigerators and found they were stored securelyand were only accessible to authorised staff. There was aclear policy for ensuring medicines were kept at therequired temperatures. We saw records that confirmed thefridge temperatures were checked and recorded. Allrecordings for the past six months were within the requiredrange. This was being followed by the practice staff, and theaction to take in the event of a potential failure wasdescribed and staff were able to confirm this to us.

Systems were in place to check medicines were within theirexpiry date and suitable for use. A check list was availableand the practice nurse used this to ensure all checks wereaccurate. All the medicines we checked were within theirexpiry dates. Expired and unwanted medicines weredisposed of in line with waste regulations.

Vaccines were administered by nurses using currentdirectives that had been produced in line with legalrequirements and national guidance. We saw a copy ofdirectives from the Clinical Commissioning Group (CCG)and evidence that nurses had received appropriate training

to administer vaccines. All vaccination batch numberswere recorded in the patient records to ensure that if analert was raised on the vaccine they could easily identifypatients who had been affected.

There was a protocol for repeat prescribing which was inline with national guidance and was followed by thepractice. Patients could request repeat prescriptions onlineand in writing. All prescriptions were reviewed and signedby a GP before they were given to the patient. Blankprescription forms were handled in accordance withnational guidance as these were tracked through thepractice and kept securely at all times.

Cleanliness & Infection ControlThe practice had an infection prevention and control policythat was in line with the Health and Social Care Act 2008Code of Practice on the prevention and control ofinfections and related guidance. The lead for infectioncontrol was the practice nurse who had undertaken furthertraining to enable them to provide advice on the practiceinfection control policy. All staff received induction trainingon infection control specific to their role and annualupdates thereafter. Audits had been carried out for the lasttwo years and any improvements identified werecompleted on time. Practice meeting minutes showed thefindings of the audits were discussed. For example theconsulting room privacy curtain, which was the property ofthe Health Centre, had expired in 2013. There was an ongoing problem in getting these changed, as the owners ofthe Health Centre had not yet acquired a suitablereplacement. The practice had identified this as a risk andwere continuing to request for a replacement.

Hand washing sinks with hand soap and hand toweldispensers were available in treatment rooms. No hand gelwas available. The practice manager told us they had beenremoved due to a fault with splashing which had causedinjuries to eyes. This incident had been recorded as asignificant report and had been reflected on during staffmeetings. Records showed that replacements had beenordered.

The practice had a policy for the management, testing andinvestigation of legionella (a germ found in theenvironment which can contaminate water systems inbuildings). We saw records that confirmed the

Are services safe?



arrangements were in place to ensure regular checks wereundertaken in order to reduce the risk of infection to staffand patients. A contracted company was used to dispose ofclinical waste.

We observed the premises to be clean and tidy and therewere cleaning schedules in place for those rooms managedby the practice. However, the practice did not have controlin the checking of communal areas as this was a sharedcommunal building and the role of cleaning and checkswas completed separately by the owners of the building.The schedules we looked at showed the frequency ofcleaning and the areas that had been cleaned. Patients wespoke with told us they always found the practice cleanand had no concerns about cleanliness or infection control.

EquipmentStaff told us that all equipment was tested and maintainedregularly and we saw equipment maintenance logs andother records that confirmed this. All portable electricalequipment was routinely tested and displayed stickersindicating the last testing date of October 2014. A scheduleof testing was in place. We saw evidence of calibration ofequipment such as weighing scales and the fridgethermometer. This had been completed in July 2014.

Staffing & RecruitmentRecords showed that the practice had not conducted allthe required recruitment checks prior to staff commencingemployment and renewed, as required. The practice hadobtained proof of identification, references, qualifications,registration with the appropriate professional body andDBS checks for all clinical staff. However administrativestaff who were acting as chaperones had not had any DBSchecks completed. It is the responsibility of the practice toensure that all the necessary checks had been undertakenbefore staff started work.

Staff told us about the arrangements for planning andmonitoring the number of staff and mix of staff needed tomeet patients’ needs. We saw there was a rota system inplace for administrative, reception and clinical staff toensure there were enough staff on duty. There was also anarrangement in place for members of staff, includingnursing and administrative staff to cover each other’sannual leave to ensure the practice maintained a safe staffmix to meet patient needs.

Staff told us there were enough staff to maintain thesmooth running of the practice and there were always

enough staff on duty to ensure patients were kept safe. Thepractice manager showed us records to demonstrate thatstaffing levels and skill mix were in line with plannedstaffing requirements. All patients we spoke with felt thatthe practice always had enough staff to attend to theirneeds.

Monitoring Safety & Responding to RiskThe practice had systems, processes and policies in placeto manage and monitor risks to patients, staff and visitorsto the practice. These included annual and monthly checksof the environment, medicines management, staffing,dealing with emergencies and equipment. The practicealso had a health and safety policy. Health and safetyinformation was displayed for staff to see and there was anidentified health and safety representative.

Identified risks were included on a risk log. Each risk wasassessed, rated and mitigating actions recorded to reduceand manage the risk. We saw that any risks were discussedat GP partners’ meetings and within team meetings. Forexample, the practice manager had identified a risk withthe building’s fire evacuation policy process. The buildingwas shared and its’ owners were responsible forconducting fire drills. No fire drills had been conducted inthe last six months. The practice manager showed us therisk log they had completed and requested action from thecompany responsible for managing the building. In theinterim the practice had devised their own fire evacuationpolicy and this had been made familiar to all staff.

We saw that staff were able to identify and respond tochanging risks to patients including deteriorating healthand well-being or medical emergencies. For example, staffwere made aware of a patient prioritising tool. Thisoutlined the action to follow for a collapsed patient orthose with crushing chest pain, which included the need tocall 999 and act as soon as possible.

The practice monitored repeat prescribing for peoplereceiving medication for mental health needs or thoseidentified as being suicidal. The GPs did not prescribeanalgesics as repeat prescriptions to this population group,to avoid risk of intentional overdoses.

Arrangements to deal with emergencies and majorincidentsThe practice had arrangements in place to manageemergencies. We saw records showing all staff had receivedtraining in basic life support. Emergency equipment was

Are services safe?



available including access to oxygen and an externaldefibrillator (used to attempt to restart a person’s heart inan emergency). All staff we spoke with knew the location ofthis equipment. The defibrillator was available for allpractices in the building and arrangements were in placefor it to be checked regularly.

Emergency medicines were available in a secure area of thepractice and all staff knew of their location. These includedthose for the treatment of cardiac arrest, anaphylaxis andhypoglycaemia. Processes were also in place to checkemergency medicines were within their expiry date andsuitable for use. All the medicines we checked were in dateand 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. Each risk was rated and mitigating actionsrecorded to reduce and manage the risk. Risks identifiedincluded power failure, adverse weather, unplannedsickness, disease outbreak and access to the building. Thedocument also contained relevant contact details for staffto refer to including the telephone numbers of all staff andthose of other practices within the area.

Are services safe?



Our findingsEffective needs assessmentStaff we spoke with were aware of the need to keepupdated with guidelines in order to improve care. Thepractice kept information folders that were easilyaccessible to staff with guidance from the National Institutefor Health and Care Excellence (NICE), British MedicalJournal (BMJ) and Department of Health (DH), amongstothers. The GPs told us that they used local guidelines andcare pathways from the local Clinical Commission Group(CCG) when making referrals and planning care. Forexample, the practice was involved in the local prescribingincentive scheme for asthmatic patients. This included“stepping down” patients with asthma on a high dose ofinhaled steroids. (“Stepping down” involves reducing thedose of steroids used by patients when their asthma isunder control). The purpose for this was to improve healthoutcomes for patients by reducing long-term use ofsteroids that can cause ill health. The practice used atemplate provided by the CCG when undertaking healthreviews for chronic patients to ensure they followed currentevidence based guidelines with the aim of improving careoutcomes. We saw minutes from CCG meetings which a GPrepresentative from the practice had attended. Thisincluded details on local initiatives that the practices wereto introduce. This was shared amongst staff duringmeetings.

Management, monitoring and improving outcomesfor peopleThe Practice had a system in place for completing clinicalaudit cycles. Examples of clinical audits included

care for patients with dementia which had been completedin March 2014. The purpose was to find out if the patientshad been reviewed in the last 12 months and if this reviewhad included a discussion around their social support. Thepractice found that 100% of their patients had been offereda review with a discussion on their social support andneeds having taken place.

The practice also used the information they collected forthe QOF and their performance against national screeningprogrammes to monitor outcomes for patients. QOF is anational performance measurement tool. The practice hadbeen identified as low prescribers for patients withRheumatoid Arthritis. An audit had been undertakenlooking at patients with Rheumatoid Arthritis and their care

and use of steroids. A total of 11 patients were identified tocomplete the audit. The audit found that four of thesepatients had been missed from the register and were nothaving suitable medicines hence the low reporting.Following the audit, these patients were added to theregister and their care was been planned accordingly. Thepractice planned a repeat audit to take place in January2015 to ensure all patients with the condition were on theregisters and receiving appropriate care.

The practice was involved with other local practices inreviewing their performance. This involved meeting withthe medicines management team from a local cluster ofpractices. Referral data and prescribing data was discussedwith improvement areas highlighted. This formed part of apeer review process.

Effective staffingThe practice had an effective recruitment and inductionprogramme. We reviewed staff training records and sawthat all staff were up to date with attending mandatorycourses such as annual basic life support ,infection controland confidentiality awareness.

All GPs were up to date with their yearly continuingprofessional development requirements and were due forrevalidation in 2015 and 2016 respectively. The practicemanager kept records for the performers list with theGeneral Medical Council and they were both up to date.The practice had records supplied by the practice nursethat showed their registration with the Nursing andMidwifery Council (NMC) was current.

Records showed that all staff had received an appraisalwithin the last 12 months. Both records reviewed anddiscussions with staff confirmed that the appraisal processwas linked to professional development. The practicenurses received appropriate training updates that enabledthem to carry out specific roles such as vaccinations andother specialist role and this training was offered regularlywithin the local cluster.

Working with colleagues and other servicesThe practice held multidisciplinary team meetings monthlywith the local palliative care team and a local hospice. Careplans for patients were discussed and updated. We sawrecords of minutes where such meetings had taken place.The GPs told us that they liaised with other services such asdistrict nurses and the local safeguarding teams. However,they pointed out that over the last two years services for

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


children in Croydon had deteriorated. In particular thehealth visiting services were moved from the local clustersand as such they did not have much involvement withthem. They had identified and raised this with the localCCG. The practice had continued to contact the lead forchildren’s services who made contact with the limitedhealth visiting service to report any concerns.

Blood results, X ray results, letters from the local hospitalincluding discharge summaries, out of hours providers andthe 111 service were received both electronically and bypost. On receipt these were stamped to show date receivedand processed on the day by a designated administrativestaff member. The practice used a computer system thatalerted the GPs or nurses of the results allocated to themand the action required. The system would highlight analert if this had not been followed up by a specific time.Staff explained that these checks were undertaken on adaily basis to ensure all results due were acted on. All stafffully understood their role and expectations from thepractice on dealing with patient results.

Information SharingThe practice used an electronic information system calledCReSS (Croydon Referral Support Service) that was usedlocally. The system ensured that referrals were within thelocal threshold and any inappropriate referrals or errorswere quickly identified and rectified to avoid delay inpatients being seen by secondary care or other specialists.The practice was notified of patients attending emergencyservices through the electronic system and this enabledfollow up care or discharge summaries to be shared in atimely manner.

Consent to care and treatmentThe practice had polices on the Mental Capacity Act 2005and the application of Gillick competencies legislation.(Gillick competence is a term originating in England and isused in medical law to decide whether a child (16 years oryounger) is able to consent to his or her own medicaltreatment, without the need for parental permission orknowledge). The GPs were able to explain to us theimportance of seeking consent and situations when theyhad to apply the Mental Capacity Act and Gillickcompetency while helping patients to consent to care andtreatment.

Records reviewed indicated consent was sought prior totreatment and situations where the GPs had to involveother patient representatives when seeking consent for

treatment. For example a patient was the main carer for ayoung man with learning disabilities. The GPs observedthat the patient had become increasingly forgetful. Theymade a diagnosis of Dementia after referral and testing.The GPs then made a referral to social services for acapacity assessment to ensure arrangements were put inplace for both the patient and their son with learningdisabilities.

Health Promotion & PreventionThe practice offered all new patients registering with thepractice a health check with the health care assistant or thepractice nurse. Any health concerns identified during thisnew patient check were referred to the GP. The GPs wereaware of the high incidence of Coronary Heart Disease inthe area and as such had introduced ECG monitoring.Electrocardiogram (ECG) records the electrical activity ofthe heart. The heart produces tiny electrical impulseswhich spread through the heart muscle to make the heartcontract. These impulses can be detected by the ECGmachine. For example, a new patient was offered an ECGand was found to have a condition that needed urgentcare. This resulted in fast tracked hospital appointmentreducing the risk of developing further complications whilston a non-urgent waiting list.

The practice offered patients a variety of health promotionleaflets. The practice nurse offered a range of healthpromotion clinics. These included baby vaccines, travelinformation and vaccinations, chronic diseasemanagement for asthma, diabetes, epilepsy, and HIV. WellMan and Woman clinics that offered advice on breastcancer and prostate cancers. Weight management anddietary advice were also available. The practices referredpatients to a local weight and exercise group.

The practice’s performance for childhood vaccines uptakewas 92.9% and the average in the CCG was 89.9%. Therewas a policy to offer telephone reminders for parentswhose children failed to attend immunisation sessions. Thedid not attend information was also shared with otherservices who might have been in contact with families. Thiswas designed to improve uptake rates. Performance resultsfor patients with diabetes receiving a yearly flu vaccinationand was 94% compared to 90% in the CCG.

The practice had an overall smear test rate of 81%. Theirperformance for cervical smear uptake for females aged25-64 with schizophrenia, Bipolar affective disorder andother psychoses was 100% which was better than the 85%



average for the CCG. There was a policy to offer telephonereminders for patients who did not attend for cervicalsmears and the practice audited patients who did notattend annually.



Our findingsRespect, dignity, compassion and empathyWe reviewed the most recent data available for the practiceon patient satisfaction. This included information from thenational patient survey and completed CQC commentcards to provide us with feedback on the practice. Wereceived 10 completed cards and all were positive aboutthe service experienced. Patients said they felt the practiceoffered an excellent service and staff were efficient, helpfuland caring. They said staff treated them with dignity andrespect. We also spoke with six patients on the day of ourinspection. All told us they were satisfied with the careprovided by the practice and said their dignity and privacywas respected.

Staff and patients told us that all consultations andtreatments were carried out in the privacy of a consultingroom. Disposable curtains were provided in consultingrooms and treatment rooms so that patients’ privacy anddignity was maintained during examinations, investigationsand treatments. We noted that all consultation andtreatment room doors were closed during consultationsand that conversations taking place in these rooms couldnot be overheard.

We observed staff were careful to follow the practice’sconfidentiality policy when discussing patients’ treatmentsin order that confidential information was kept private. Thepractice switchboard was located away from the receptiondesk and was shielded by glass partitions which helpedkeep patient information private.

The practice had a chaperone policy and details of how torequest a chaperone were displayed in areas easilyaccessible to patients. Records confirmed that staff hadcompleted the chaperone training at the practice. Staff wespoke with were able to fully explain what the role involved.

Care planning and involvement in decisions aboutcare and treatmentWe reviewed three patient records. We noted that allpatients had been involved in the care planning of theircare. Decisions on the care options available had beendiscussed fully.

We noted that were appropriate patients had beeninvolved in making decisions on hospitals they wished toreceive their care from. Some patients told us that the GPsrespected their decisions of requesting care at hospitals

that were not within the area. Data from the nationalpatient survey showed that, 72% of respondents said thelast GP they saw or spoke to was good at involving them indecisions about their care compared to 68% from the localCCG average. The practice worked closely with the end oflife care teams and helped their patients to make end of lifedecisions. The practice provided information onindependent organisations such as Age Concern to itspatients.

All GPs were aware of their role in making best interestdecisions and understood the Mental Capacity Act 2005and the concept of Gillick Competency. Gillick competencyis a term used in medical law to decide whether a child 16years or younger is able to consent to his or her owntreatment. The GPs told us that they applied the conceptcarefully whilst also taking into consideration the culturalimpact for example when prescribing contraception to achild below 16.

The practice had a Patient Participation Group (PPG).Thegroup had recently started. The PPG had meetings everythree months. We spoke with three members from thegroup. They told us that they had not been involved insurveys as yet but had requested the practice to producean information leaflet about local support services and thishad been done. Data from the 2014 national patient surveyshowed that the majority of patients rated the practice as“very good”. The practice had sent out 384 surveys; 115responses had been received and 79% said the last GP theysaw or spoke to was good at listening to them.

Patient/carer support to cope emotionally withcare and treatmentThe practice provided support to its patients duringperiods of bereavement. Information leaflets wereavailable at the practice containing the list of supportorganisations available. Staff told us that due to the size ofthe practice, the GPs kept in touch with relatives who hadlost a loved one and offered supported. Two patients toldus the GP had written to them during the loss of their lovedones. The GPs referred patients for counselling whenneeded. The practice also kept a record of deceasedpatients in the reception area for staff to quickly identifybereaved families to ensure extra sensitivity when dealingwith them. The practice worked closely with the End of Lifecare team. They referred patients and relatives to thisservice for support.

Are services caring?


Our findingsResponding to and meeting people’s needsWe 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 wereunderstood and systems were in place to addressidentified needs. The practice used the CReSS (CroydonReferral Support Service) risk tool, which helped doctorsdetect and prevent unwanted outcomes for patients. Thishelped to profile patients by allocating a risk scoredependent on the complexity of their disease type ormultiple comorbidities. For example, the area had a highprevalence of diabetes. The practice offered screening to allpatients who registered at the practice. Screening was alsoavailable to patients already registered who presented withsymptoms to ensure early diagnosis and better outcomes.

The Local Clinical Commissioning Group (CCG) told us thatthe practice did not regularly engage with the CCG todiscuss local needs and service improvements that neededto be prioritised. However the GPs told us and showed usevidence that one of the GPs attended local CCG meetingson a regular basis but did so representing two practicesand the attendance was only noted for the other practice,an error they were trying resolve. We saw minutes ofmeetings of attendance and actions agreed to implementservice improvements. The minutes demonstrated thepractice was involved in joint working and integratedpathways with other services such as district nursesdelivering care to the elderly.

The practices reduced inequalities by ensuring the surgerywas accessible to patients from all groups. Patients had achoice of seeing a female or male GP at the surgery. BothGPs had been working at the surgery for a number of yearsand had developed relations with patients which allowedcontinuity of care. The practice used the same locum staff ifneeded and so patients were also familiar with them.

Patients who were too ill to attend the surgery were visitedat home by the GPs. This also included home visits for fluvaccines for patients who were housebound. Staff told usthat longer appointments were available to patients thatneeded them such as elderly, patients experiencing poormental health or those with chronic disease and we sawexamples of this on the bookings screens.

Tackling inequity and promoting equalityThe practice had not introduced an online system forpatients to book appointments. The practice told us thatthey were in the process of arranging a pilot of an onlinesystem although no date had been set. No patients wespoke with raised concerns about the lack of an onlineappointment system. Results from the national patientsurvey showed that 90% of respondents at the practicedescribe their experience of making an appointment asgood compared to 74 % for the CCG area. Online facilitieswere available for repeat prescription requests.

All patients and members of the PPG we spoke withreported being happy with the current appointmentssystem at the practice. Patients felt that the practiceprioritised emergency appointments and working patientsdid not experience difficulties because of the extendedhours that were offered. We saw that parents attended thepractice in the afternoon after children had finished school.They told us that they were given the option to bringchildren at this time to ensure they did not miss school ifthey needed to see a GP or nurse.

We asked staff to explain the process of requestingemergency appointments .They were clear in explaining theprocedure and how they would transfer all urgent calls tothe on-call GP for triage. We were shown emergencyappointments that were available on the day of ourinspection. These appointments included slots for childrenand the elderly.

The practice was accessible to patients from disadvantagedgroups such as asylum seekers, travelling communities orthose with learning disabilities. They ensured healthpromotion interventions such as smoking cessation, smearchecks and family planning were available for thesepatients as well .Staff had completed diversity training tohelp them understand the different needs of patients.

Access to the serviceThe practice opened at 08:30am and closed at 18:30Monday to Friday. Extended hours were available onMondays and Thursdays until 19:30 which was useful forworking age patients. There were arrangements in place toensure patients received urgent medical assistance whenthe practice was closed. If patients called the practice whenit was closed, there was an answerphone message giving

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


the telephone number they should ring depending on thecircumstances. Information on the out-of-hours service wasprovided to patients on notice boards and contained in thepractice leaflet.

All patients we spoke with were satisfied with theappointments system. They confirmed they could see adoctor on the same day if they needed to and they couldsee another doctor if there was a wait to see the doctor oftheir choice. The GPs operated a telephone triage systemwhere urgent; patients would be offered same dayappointments or a consultation over the telephone.

The practice was situated on the ground floor. We saw thatthe waiting area was large enough to accommodatepatients with wheelchairs and prams and allowed easyaccess to the treatment and consultation rooms. Accessibletoilet facilities were available for all patients attending thepractice including baby changing facilities.

The majority of the practice population were Englishspeaking. Staff told us that they requested interpretationservices if a patient need them. The interpretation servicewas available via the telephone.

The practice website had information relating to patientsurveys and minutes from the PPG meetings. The practicewas due to pilot the use of online services for bookingpatient appointments.

Listening and learning from concerns & complaintsThe practice had a system in place for handling complaintsand concerns. Their complaints policy was in line withrecognised guidance and contractual obligations for GPs inEngland and there was a designated responsible personwho handled all complaints in the practice.

We saw that information was available to help patientsunderstand the complaints system .This was included inthe practice information leaflet and displayed in thereception area. Patients we spoke with were aware of theprocess to follow should they wish to make a complaint.None of the patients spoken with had ever needed to makea complaint about the practice.

We looked at three complaints received in the last 10months. All complaints had been dealt with in a timelymanner and had been resolved. We also noted allcomplaints had been discussed and shared with all staff atpractice meetings.

The practice reviewed complaints on an annual basis todetect themes or trends. We looked at the report for thelast review in 2013 and no themes had been identified,however lessons learnt from individual complaints hadbeen acted upon. The practice welcomed comments frompatients. These were via a suggestion box. Staff told us thiswas checked monthly and common themes were feedbackin meetings with solutions. Meeting minutes we sawconfirmed this.

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


Our findingsVision and StrategyThe practice had a clear vision to deliver high quality careand promote good outcomes for patients. This was clearlydisplayed in the patient waiting area and included in thepractice patient leaflet. All staff we spoke with were awareof the vision and were able to tell us how they contributedto the values. Staff yearly performance reviews weremonitored using the practices vision of delivering a caringservice to patients.

Governance ArrangementsThe practice had governance arrangements in place.Practice policies were easily accessible to staff. All policieswere current and it was evident they were reviewed on ayearly basis. Staff had also signed to confirm they had readand understood the policies.

The practice used the Quality and Outcomes Framework(QOF) to measure its performance. The QOF data for thispractice showed it was performing in line with nationalstandards. We saw that QOF data was regularly discussedat monthly team meetings and action plans were producedto maintain or improve outcomes.

The GPs were members of a local peer review group withinthe Clinical Commissioning Group. We had been notifiedthat the practice had failed to attend the required numberof sessions. However, during the inspection were able toascertain that one GP had attended these meetings, but asthey were representing the other practice, this had notbeen counted.

The practice had completed a number of clinical auditsbetween 2013 and July 2014. For example an audit hadbeen completed on dementia patients diagnosis andfurther care. The purpose was to ensure that patients wereoffered screening at the appropriate levels and thisscreening included physical health, blood test and otherenvironmental needs.

Another audit had been completed in relation toRheumatoid Arthritis to ensure patients were receivingadequate care. A consequence had been that another fourpatients not known to have Rheumatoid Arthritis had beenidentified and added to the disease register.

The practice had robust arrangements for identifying,recording and managing risks. The GP showed us their risk

log which addressed a wide range of potential issues. Forexample, the practice kept a log of patients who had beenreferred to other services and were awaiting follow up. Toensure that these patients were not missed, the GPsconducted regular checks to ensure that they had beenseen or at least received confirmation of an appointment.The senior GP had also produced a list of “must do”, forlocum GPs. This highlighted all clinical protocols ensuringthat risk was minimised when they worked in the absenceof permanent staff.

Leadership, openness and transparencyThe leadership structure of the practice was clear to allstaff. All four staff we spoke with told us who the leadperson was at the practice, including the leads forsafeguarding and infection control. It was clear that staffwere aware of their roles and responsibilities with clearaccountability.

Records showed that team meetings were held monthly.Staff told us that there was an open culture within thepractice and they had the opportunity and were happy toraise issues at team meetings or at any time with thepractice manager or GP.

The practice manager was responsible for human resourcepolicies and procedures. We reviewed a number ofpolicies, such as disciplinary procedures, induction policyand management of sickness which were in place tosupport staff. All policies were up to date. Staff we spokewith knew where to find these policies if required.

Practice seeks and acts on feedback from users, public andstaff

The practice had an active Patient Participation Group(PPG). The PPG contained representatives from variouspopulation groups, including the retired and working agepopulation. The PPG held regular meetings. They had notconducted any surveys as yet .However they had identifiedthe need to have information on local services availablefrom a single reference point. With their help the practicehad designed a leaflet named, “a helping hand”, whichcontained information on all local support groups andservices.

The practice had gathered feedback from patients throughpatient surveys. We looked at the results of the annualpatient survey from 2013. The majority of patients hadreported being happy with the practice and this includedaccess to appointments.

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


The practice had gathered feedback from staff through oneto one meetings or via a record book. Staff told us theywere never afraid to share their views and feedback wasencouraged.

Management lead through learning &improvementStaff told us that the practice supported them to maintaintheir clinical professional development through trainingand mentoring. The practice nurse told us that they weresupported to attend a local nurses forum were informationwas shared which improved their knowledge and practice.

A member of the administrative staff had identified theneed to be involved clinical work as career development.They were being supported to access training and practiceto enable them to become a health care assistant.

The practice had completed reviews of significant eventsand other incidents and shared with staff via meetings toensure the practice improved outcomes for patients. Forexample, a patient had previously undergone a number ofblood tests. A number of abnormalities had been missedincluding a raised blood glucose and cholesterol. Thepatient had a diagnosis of diabetes that had not beenfollowed through. Following this incident the practice nowused EMIS an electronic system to flag such findings toavoid future occurrences.

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 essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityRegulation 21 HSCA 2008 (Regulated Activities) Regulations2010 Requirements relating to workers

Regulation 21 HSCA (Regulated Activities) Regulation2010 Requirements Relating to Workers.

How the regulation was not being met:

The registered person failed to ensure that there wereeffective recruitment procedures in place in order toensure that people employed in the service were of goodcharacter. Regulation 21 (a) (i)

Staff acting as chaperones did not have Disclosure andBarring Service checks.

Regulation

This section is primarily information for the provider

Compliance actions


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