Learning from Inspection Fails
GP Practices case studies
CQC Regulations came into force from 1st April 2013, and practices are already undergoing inspections. The registration process asked practices to certify that they meet the compliance standards set under the CQC regime, and practices are required to have made themselves familiar with the CQC Guidelines issued by the Care Quality Commission.
Although every practice has certified that they are compliant or that they have an action plan in place, alarmingly, anecdotal evidence suggests that up to 95% of Practice managers may not even have read the CQC guidance.
“We were the first independent organisation to hold CQC seminars for GP practices, and when we asked this question in 2011, hardly any hands went up” says Shabana Dehlavi, the editor of Everything CQC. “But what will be surprising to many is that the same applies, even today”.
If these straw polls were to be extrapolated to the general GP population, it would indicate that up to 95% of the practices have not read the Guidelines or gave up part of the way through, usually after reading just the first few pages. So if you too have not read the CQC Essential Guidance then it looks like you are in good company.
Most providers find the Guideline a difficult read because of the ‘bureaucratic’ language used. Trying to ‘decipher’ the meaning of a single sentence can sometimes take quite some time, and most just give up mentally exhausted.
An example of this language is Prompt 3E about Fees, to be found on page 59 of the Guideline.
Contrast what the Guideline says:
“People who use services who pay the provider in full for their care, treatment and support and people who use services who enter into a separate arrangement with a service provider because they choose to pay for care, treatment and support that is not contracted on their behalf by a third party purchaser…”
What it means in plain English:
“If the patient pays for the entire treatment out of their own pocket, then …...”
The Guideline, is some 278 pages long, and it is not difficult to see why readers describe it as a cure for insomnia.
On a serious note, without a full understanding what the requirements are, practices are in danger of mis-declarations, and carrying on doing the wrong things for the rest of the year. This should be of great concern to GPs, especially Registered Managers, who may be held accountable.
The Care Quality Commission (CQC) has successfully prosecuted Dr Hassan Abdulla, a doctor based in Leicester, has been fined £2,700 and ordered to pay over £30,000 in court costs after he admitted to performing circumcisions without being registered.
Fiona Allinson, compliance manager for the CQC, said: “This sends a clear message to any health care professionals that they not only need to ensure they are registered with CQC but we will take action against those who fail to do so”.
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Two GP surgeries are closed by court order ‘with immediate effect’ for first time in East Anglia, The Eastern Daily Press reported.
Two doctors’ surgeries, with more than 5,000 registered patients in the Lowestoft area, have closed as urgent legal action was taken following “serious concerns about the service and the risks it presented to patients”.
The CQC has cancelled the registration of Oulton Medical Centre and its satellite branch of Marine Parade Surgery, a first “urgent cancellation of a GP’s registration” in Suffolk, Norfolk or Cambridgeshire, under a Section 30 order of the Health and Social Care Act 2008.
What does this mean for GPs?
This is not new to those operating care homes and dentists who are not given second chances in such cases. So far, GPs have been isulated from strict measures and treated with kid golves by the CQC, thanks largely to the influence of the BMA and GMA.
This was the result of an unannounced inspection in March 2015, when the services were rated inadequate and placed into special measures. In a follow up visit in October the CQC said: “Further concerns were identified in relation to a lack of clinical leadership and a failure to learn from errors, meaning patient wellbeing was placed at risk.”
Amazingly, the PPG co-ordinator said "the closure came as as a surprise and a shock to the patients",s o once again we see a practice deemed perfectly adequate by the patients as well as the PPG, and yet the CQC find things that demand immediate closure.
This is not a criticism of the CQC, far from that, it demonstrates that patients are often ill informed about what constitutes a safe practice.
This is a lesson for practices not to be lulled into a false sense of security by positive comments by patients as they might simply be impressed by great service rather than great care.
The CQC has informed Everything CQC that of the 7,607 of GP practices registered with the CQC some 20% (1,545) have declared non-compliance with at least one of the CQC’s 16 essential standards.
The CQC states that ‘the two biggest areas of declared non-compliance were around premises and infection control’.
At the time of Registration, providers were entitled to declare non-compliance with the regulations but were required to submit an action plan setting out how they planned to become compliant together with timescales.
1. The 20% figure does not take into account potential misdeclarations at registration. Our audits indicate actual non-compliance to be as much as 40% or more because many practices declared full compliance at the time of registration in the hope of ‘catching up’ by April 2013.
2. To avoid penalty notices or other serious consequences we strongly recommend that you put your ‘house in order’ in accordance with the action plan agreed with the CQC or the level declared at the time of registration.
3. It was revealed last month that practices have spent an average of £2500 just to get through registration. This cost will increase if practices are still not compliant.
|Outcome||Number of primary care service providers that declared non-compliane with the outcome|
|Respecting and involving people who use services||291|
|Consent to care and treatment||211|
|Care and welfare of people who use services||258|
|Meeting nutritional needs||58|
|Cooperating with other providers||196|
|Safeguarding people who use services from abuse||523|
|Cleanliness and infection control||863|
|Management of medicines||142|
|Safety and suitability of premises||810|
|Safety, availability and suitability of equipment||237|
|Requirements relating to workers||269|
|Assessing and monitoring the quality of service provision||230|
Southfields - Granville Road Surgery
We have already covered how a south London practice got suspended earlier this year. Although "suspension" implies something temporary, the consequences could be catastrophic and end up in closing you down altogether.
Looking beyond the fate of that practice, we should all be worried, even if we are not "that" practice. So what are the potential consequences of a suspension?.
Your patients get transferred, probably to a nearby NHSE site, until you are ready to open your doors again. It is quite likely that many will not return once they have lost confidence in your ability to look after them.
In this case the local Guardian focused purely on all the issues that would strike a chord with patients and something they can visualise easily, such as dirty rooms. The image of a filthy practice where you will catch something, is difficult to shake off. Put yourself in the patient's shoes, and visualise a restaurant that Health & Safety has suspended for FOUR MONTHS. How bad would it have been? Can you ever trust them again? Would you take little kids there, ever?
When you Google Dr Mujib ul Haq Khan, all the bad news comes up before details of his surgery, this is what prospective patients will see first. The reputational damage could be irreparable.
Your Federation will have to think twice before giving you a slice of contracts. In fact, this could be suicidal for them in the short run at least. So your immediate avenues to new revenues is cut off immediately.
What will the CCG do?
Any CCG would rightly be cautious about any practice that has been suspended, and logically, even the Federation that your practice belongs to should be subject to more scrutiny. What sort of membership do they have? Do they check the quality performance of their members before bidding for contracts?
Look past the obvious failures highlighted by the CQC, the real risk of your practice being caught out could be a lot higher than you imagine, and could even be existential.
If you are currently part of a Federation, it is in your interests to make sure that a poor performing member does not risk and sink your Federation.
Here is an interesting case of how Patient Safety interacts with compliance.
The CQC inspectors closed down the surgery of Dr Mujib ul Haq Khan of Granville Road Surgery in London. Dr Khan decided to take the CQC to a tribunal court, disputing several of the inspector's findings. His appeal was ‘unanimously dismissed’.
Dr Khan's viewpoint:
He is quoted as saying ‘I am disappointed by the decision of the tribunal, but I am grateful that it acknowledged my practice had run for 33 years, “without incident” and with very few complaints. I have been with the NHS for 45 years.'
He also contends that the CQC looked at hypothetical scenarios and "The decision to close my surgery did not relate to any actual treatment of my patients, for which no criticism has ever been made by either the GMC or the CQC"
So why does a practice with an "impeccable" record get closed down by the CQC?
The lesson to learn is that maybe nothing ever went wrong, BUT if you cannot demonstrate that you are taking prevention measures, YOU become the risk.
- Checks on staff had not being undertaken prior to their employment, and that the practice did not have systems in place for responding to risk.
- That, in the Tribunal’s view was indicative of Dr Khan’s careless, passive and reactive approach to the management of his practice.
- Lack of any adequate induction procedure for new locum doctors.
- Absence of any Disclosure and Barring Service check
- Hepatitis status check or references
- Lack of child protection or adult safeguarding policies
- Lack of adequate staff fire training.
GPs Point of view
- CQC acknowledged my practice had run for 33 years, “without incident” and with very few complaints.
- I have been with the NHS for 45 years.
- This is after all a decision by the CQC based largely on issues such as the keeping of records, fire risk assessments, extension cables and hypothetical scenarios.
- The decision to close my surgery did not relate to any actual treatment of my patients, for which no criticism has ever been made by either the GMC or the CQC
Dr Khan's performance was described as "careless, passive and reactive approach to the management of his practice".
The acid test for any independent audit is that you have to be able to demonstrate to a total stranger that you did what you said you did, when you said you did it.
A company providing cosmetic surgery treatment at independent clinics in Wakefield and London without being properly registered has been ordered to pay a fine of £40,000 by magistrates in Wakefield
In addition the company was also ordered to pay the Commission's costs of £22,54889
Amanda Sherlock, CQC Director of Operations, said: “Neither the company nor the locations where treatment was being carried out were registered so people using the service were at risk of receiving treatment which did not meet the standards required by law”
In January 2013, two GP practices were issued with a ‘notice proposing to refuse registration’ because they had failed to respond to correspondence from the regulator, after concerns about standards had been raised by the GMC or by the practices themselves.
The practices again failed to submit an appeal within the 28 day period against the notices so the CQC has decided not to register them, meaning they will be open their doors to patients from the 1 April.
Trading without registration is an offence. In plain English, this means you will be committing a criminal offence and liable to hefty fines and prosecutions
However the GP practices have another 28 days to submit and appeal and challenge the decision.
Cautionary tale for Registered Managers:-
- Make sure the Registered Manager sees all correspondence from CQC
- Respond to the CQC as soon as you can, ignoring correspondence could be fatal.
- Action will be taken against practices who are reported by 3rd parties, especially the likes of the GMC
- Non-compliance has consequences
- CQC does have teeth
CQC inspectors have told West Street Dental Practice in Congleton, Cheshire, that it is not meeting essential standards and must improve.
We have identified major concerns in six different areas including:
- the care and welfare of people who use services
- cleanliness and infection control
- availability and suitability of equipment
- requirements relating to workers
- staffing and supporting staff
Our inspectors found risks of cross contamination as overfilled bags of clinical waste were being stored near clean items
Insufficient staff members without the right knowledge, skills and experience meant that people were at risk of not having their health needs met
This review is the first to identify major concerns about a dental provider
Pulse reports that a GP practice in Solihull has been told, by NHS managers, that their surgery was non-compliant with infection control rules and must have a £300,000 refurbishment in order to prepare for CQC inspection. The PCT would contribute £200,000 but the GP would have to meet £100,000 of the costs.
The practice, told Pulse: ‘The PCT infection control told us the practice would be non-compliant with CQC Outcome 8 and we needed to remove all the carpets, replace all stippled ceilings, remove all the skirting boards and have heavy duty lino going up the walls to become compliant.”
When approached by Pulse with details of the case, a CQC spokesman has said: ‘We won’t refuse any registration just because you don’t have modern or state-of-the-art premises. We’ll only take action if patients are being put at risk by unsafe premises. Equally rumours such as carpets and soft furnishings in waiting rooms will have to be removed due to infection issues control are absolutely false. These are matters that are not likely to cause the CQC any concern, or lead to non-compliance with the essential standards of quality and safety.’
- What is interesting is that whilst the CQC has confirmed that they won’t refuse ‘registration’; they have not said whether they will take the same attitude when they come down for an inspection.
- Do you believe that if an inspector picked up the same point as the PCT, they will be as generous about letting you off the hook?
- The PCT said ‘It is up to the individual practices to develop and implement an action plan in response to those recommendations. We provide advice and guidance.’ (Not to mention the free £200,000)
- If someone is gifting you £200,000 and you have to contribute £100,000, perhaps you should make a business decision as to whether this is a profitable proposition for you.
- Before you spend any money, look at our guidance on fixtures and fittings CLICK HERE
CQC’s investigation into Barking, Havering and Redbridge University Hospitals NHS Trust (BHRT) has revealed serious failings throughout the entire trust.
Despite some signs of improvement in recent months, patients still remain at risk of poor care, particularly those receiving maternity services.
Problems found in maternity services include:
- poor clinical care.
- abusive and unprofessional behaviour from staff.
- a lack of learning from maternal deaths and incidents.
- lack of leadership from senior management.
Other areas of concern:
- A&E services at Queen’s Hospital struggled to meet the target for admissions.
- Staff vacancies were filled by agency, locum or bank staff which had an impact on the quality of care.
- Lines of communication within the new structure were unclear.
- Trust governance systems and corporate governance were weak.
- Response to complaints was poor.
Adult Care case studies
The Care Quality Commission (CQC) has cancelled the registration of the manager of a London care home where residents had been assaulted by staff – and that decision has now been upheld by a care standards tribunal.
The Southwark tribunal heard that concerns regarding the way the home was being managed by Ms Oluku came to light when a care worker, Slawomira Kowalkowska, secretly filmed two of her colleagues abusing people living there. This evidence triggered an unannounced inspections by CQC in September 2010, which was followed up in November 2010.
Since that time CQC has worked closely with local commissioners, social services and the police to make sure people living at the home are protected. CQC has carried out four further inspections to follow up on the concerns raised.
A care home worker who abused a resident at a home in London has been sentenced today
Jonathan Aquino, 30, was sentenced to 18 months, half custodial and half on licence, for abusing an 80 year old woman with dementia at Ash Court Care Centre, Camden, in June last year
Camden Council’s safeguarding team, the police and CQC were alerted to the abuse on 23 June 2011 The family of the resident, concerned by the treatment their mother had received, had secretly filmed the abuse
Matthew Trainer, CQC’s Deputy Director of Operations in London, said: “CQC welcomes the sentence handed down today It is right that this behaviour has been handled robustly by the police and the courts This sends a strong message that it is unacceptable to abuse an elderly person in your care We hope it will act as a powerful deterrent to others”
36 Roseberry Gardens, a care home in Haringey, North London has closed after falling short of the essential standards of quality and safety
During two unannounced inspections last year, CQC inspectors found that the home was failing to meet 11 of the essential standards that people are legally entitled to expect
During the inspections, the inspectors witnessed:
- one of the providers loudly reprimanding a person living at the home for assisting the CQC with their inspection
- poor standards of cleanliness
- a lack of safety precautions around potential fire risks
Melbury House care home was falling short of the essential standards of quality and safety.
The results of the inspections show:
- health and social care professionals had concerns about how prospective residents were assessed prior to admission to the home.
- a number of staff had not undertaken essential training for their roles.
- monitoring of the quality of service provided was ineffective.
- people lacked confidence that risks to their health, safety and welfare were not properly reported so that action could be taken.
The provider voluntarily cancelled its registration at the site.