Dr A T Fernandes and Partners Also known as The Parchmore Partnership

Updated 7 June 2017

Dr A T Fernandes and Partners provide services to approximately 14,400 patients in South West London under a Personal Medical Services contract (an agreement between NHS England and general practices for delivering personal medical services). It sits within the Croydon Clinical Commissioning Group (CCG) which has 61 member practices serving a registered patient population of approximately 389,000. In 2010 this was the first practice in Croydon to achieve the RCGP Quality Practice Award. Dr A T Fernandes and Partners provide a number of enhancedservices including extended hours access; improving patient online access; influenza and pneumococcal immunisations; facilitating timely diagnosis and support for people with dementia; minor surgery and rotavirus & shingles immunisation. The practice provides between 56 and 69 GP sessions per week, depending on the number of locum GPs engaged.

The staff team at the practice consists of four male and eight female GPs, one nurse practitioner and five practice nurses, four health care assistants; a managing partner and a general manager, an assistant practice manager and 24 administrative staff. This is also a GP training practice. The service is provided from this location only although the partnership encompasses two other, separately registered locations. There is wheelchair access to the building; lift access to the first and second floors, an accessible toilet, a hearing loop and reserved parking for patients with disabilities.

The practice is open between 8am and 6.30pm each weekday. On Tuesdays the practice is open until 8pm, and on Saturdays it is open between 8.15am and 12.15pm. Appointments are available between 8.30am – 12pm and 2pm – 6.30pm each weekday except Tuesdays when appointments are available until 7.40pm; and Saturdays when pre-booked appointments are available between 8.30am and 11.45am. Patients who wish to see a GP outside of these times are referred to an out of hour's service. The practice provides an online appointment booking system and an electronic repeat prescription service.

The practice is registered with the Care Quality Commission as a partnership to carry on the regulated activities of maternity and midwifery services, treatment of disease, disorder or injury, family planning, surgical procedures, and diagnostic and screening procedures.

The practice has a lower percentage than the national average of people with a long standing health conditions (42% compared to a national average of 54%). It has a higher percentage of unemployed people compared to the national average (8.2% compared to 5.4%). The practice sits in an area which rates within the fourth most deprived decile in the country, with a value of 29.3 compared to the CCG average of 23.6 and England average of 21.8 (the lower the number the less deprived the area). Life expectancy in this area is the same as the England average for men (79 years) and women (83 years).

The practice is located in a diverse borough with around half of the population from black and ethnic minority groups and where more than 100 languages are spoken as a first language. For example a high percentage of patients speak Urdu, Guajarati, Polish, Punjabi, Hindi, Portuguese,

Bengali and French. The patient population is comparative to, though slightly above, the England average for almost all age groups up to the age of 54. From 55 onwards the practice had a lower number of patients in each age bracket than the England average.

Updated 7 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A T Fernandes and Partners on 2 August 2016. The overall rating for the practice was Good; however the practice was rates as Requires Improvement for the key question ‘are services well led’. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr A T Fernandes and Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 2 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as Good. Specifically, following the focused inspection we found the practice to be good for providing well led services.

At our previous inspection on 2 August 2016, we rated the practice as requires improvement for providing well led services as the provider had not established governance systems and processes to enable the practice to operate effectively, including addressing action plans– such as those arising from risk assessments; introducing systems to monitor compliance with NICE and other guidance; ensure risk assessments are up to date, and carry out regular fire drills.

We also highlighted other areas where the provider should take action:

• Take appropriate steps to identify patients who are also carers to allow the practice to provide support and suitable signposting.

• Regularly review complaints received so as to establish if there are any trends developing and if so, take appropriate action.

• Complete audit cycles by re-auditing.

• Enable staff to undergo adult safeguarding training.

• Revise the infection control audit template so that it covers all areas of potential infection risk; and review the needlestick injury guidance so that the infection prevention control policy and guidance posters give the same advice.

• Carry out annual reviews on vulnerable patients, including those with a learning disability, dementia and mental illness.

• Keep records to indicate when clinical equipment is cleaned.

• Review the outcomes of the national patient survey and consider ways to improve patient experiences.

• Ensure all GPs have appropriate medical indemnity insurance in place.

Our key findings at this focused inspection were as follows:

We found that the provider had taken action to address the breaches of regulation identified at our previous inspection.

The provider had introduced new governance systems, and updated existing ones. Changes included holding weekly operational meetings, with a practice wide senior management team meeting every fourth week.

A system to monitor NICE and other guidance had been instigated, and included assessing how well the practice was complying with the guidance.

Risk assessments had been updated and were regularly reviewed. Fire drills had been carried out.

We also found that the provider had taken the following action to address the areas where we suggested they should make improvements:

• The practice had taken steps to improve its identification of patients who were also carers. Information had been added to the practice website and practice leaflet. A poster had been placed in the waiting area, and staff used ad-hoc opportunities, such as during the flu jab campaign, to contact carers. The number of identified carers had risen from 48 at the last inspection to 71 (0.5% of the patient list) at the time of this inspection.

• Reviews of complaints had been carried out and shared with the patient participation group. The practice found that most complaints related to the telephone system and appointment booking process, both of which they were taking steps to address. Technical issues had been found with the phone system which the telephone provider was working to address. The practice acknowledged that there were sometimes difficulties with appointments, not least because of a shortage of GPs. They were trying to work around this by, for example, appointing a pharmacist, and setting up a local community development programme. This programme aimed at reducing patient dependency and encouraged patients to consider alternatives to visiting their GP. The programme included setting up hubs to provide, for example, fitness classes; education and vocational training, food banks; finance and housing advice and tea and coffee clubs. To date, the practice had secured funding to set up three classes, in the community, for older people – including a health and fitness group and a health session.

• Senior staff were now logging when initial audits were carried out, and setting diary notes to ensure audits cycles were completed with a second cycle. Details of audits to be completed were also added to the practice’s action plan so that they were regularly reviewed. The practice had carried out a complete audit with regard to NICE guidance recommending all new patients should be offered an HIV test.

• We were provided with a spreadsheet outlining staff training. It indicated that all permanent staff had undergone adult and children safeguarding training to the appropriate level, with one exception amongst the administrative team. This person had training booked to take place within the next few days.

• The practice’s infection control audit template had been revised and now covered all areas of potential infection risk. The needlestick injury policy had been updated and both the policy and posters highlighting the action to be taken in the event of a needlestick injury both now gave the same information.

• The practice told us they were prioritising annual care plan reviews for vulnerable groups. At the end of the last (financial) year, 81% of patients with a mental health illness; 75% of patients with dementia and 47% of patients with a learning disability had received a review. The practice acknowledged that they had still not achieved their 100% target; however these figures were an improvement since the last inspection.

• Staff were keeping a record to show when clinical equipment was being cleaned.

• We were told staff had used protected learning time to sit down as a group to review the results of the national patient survey and identify areas for improvement. Key issues in the survey corresponded to complaints received, and were areas where the practice was already trying to improve, such as telephone access and appointments.

• Details of all the GPs’ medical indemnity insurance was now being kept centrally on the training spreadsheet and renewal dates were being diarised. The practice told us all GPs’ indemnity was in place and up to date. We saw this was the case in the staff file we reviewed.

However, there remained areas of practice where the provider should make improvements.

Importantly, the provider should:

• Continue to prioritise annual care plan reviews for vulnerable groups, particularly those with a learning disability.

• Continue to take appropriate steps to improve identification of patients who are also carers so as to be able to provide appropriate support and signposting to this patient group.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 18 November 2016

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. The general manager maintained a list of house bound patients and regularly sent a copy to the GPs to act as a reminder to review these patients’ care plans.

• Data showed outcomes for patients with diabetes were comparable to CCG and national averages. For example, the percentage of patients with diabetes, on the register, in whom

  the last IFCC-HbA1c was 64 mmol/mol or less in the preceding 12 months (01/04/2014 to 31/03/2015) was 69% (CCG average 72% and national average 78%). The percentage of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months (01/04/2014 to 31/03/2015) was 88% (CCG average 87% and national average 88%). The percentage of patients with diabetes, on the register, who had had influenza immunisation in the preceding 1 August to 31 March (01/04/2014 to 31/03/2015) was 96% (CCG average 90% and national average 94%.

Updated 18 November 2016

The practice is rated as good for the care of families, children and young people.

• There were systems in place to identify and follow up children who were at risk, for example, children and young people who had a high number of A&E attendances. The practice had an alert system in place to identify children, and parents and siblings of children, who were on a child protection register. Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• The practice’s uptake for the cervical screening programme was comparable to the CCG and England average (80.7% compared to 81.9%). Cancer data showed the practice rate of screening females’ ages 50-70 for breast cancer in the last 36 months was 58% compared to the CCG average of 60% (England average 72%); however those screened within 6 months of invitation was 33% compared to the CCG average of 68% and England average of 73%. The number of patients aged 60 – 69 screened for bowel cancer in the last 30 months was 42% compared to the CCG average of 51% and England average of 58%. Those screened within 6 months of invitation was 40% compared to the CCG average of 48% and England average of 55%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 18 November 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• All patients over 75 had a named GP.

• Annual flu vaccinations were offered to this group, and carried out at home for the housebound patients.

Updated 18 November 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• Student’s home from university for holidays could register on a temporary basis.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• The practice had reviewed its appointment system to provide more flexibility by increasing the number of pre-bookable appointments.

Updated 18 November 2016

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia).

• 74% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months (01/04/2014 to 31/03/2015), which was 11% below the CCG average and 10% below the national average. The practice provided us with more recent statistics (01/04/2015 to 31/03/2016) which showed the percentage of reviews had slightly dropped to 73%. Following the factual accuracy process the provider sent us unverified 2015/16 data which showed the number of reviews had improved to 76%.

• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (01/04/2014 to 31/03/2015) was 64% compared to the CCG average of 85% and England average of 88%.At the time of this inspection, the practice stated that 112 of 162 patients on the mental health register had had an annual review of their care plan, which equated to 69%. Following the factual accuracy process the provider sent us unverified 2015/16 data which showed the number of patients with an agreed care plan had risen to 95%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• Staff had a good understanding of how to support patients with mental health needs and dementia, for example one of the reception staff had recently attended a dementia awareness course.

Updated 18 November 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances such as those with a learning disability. There were 76 patients on the learning disability register. Nineteen of these had had an annual review since the start of the year.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients. Monthly multi-disciplinary meetings were held with social services, the community matron and other representatives such as a mental health worker.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.