Patients from Hove who thought they were seeing a doctor were treated by someone without the relevant qualifications, an official report has found.
Medicines at Goodwood Court were out of date, it was not possible to be sure they had been stored at the right temperature and some were left in an open consulting room.
And criminal records checks were not carried out on GPs (general practitioners), according to the Care Quality Commission (CQC).
In a report published today (Thursday 27 August) by the CQC the chief inspector of general practice Steve Field explained why Goodwood Court was closed without warning in June.
The closure left 10,000 patients without a doctor although they are now being looked after by doctors at the Charter Medical Centre, a nearby practice in Hove.
Professor Field said that patients were at serious risk of harm, prompting an urgent court case when magistrates agreed that the practice should shut.
He said: “We carried out an unannounced comprehensive inspection at Goodwood Court Medical Centre on (Thursday) 4, (Monday) 8 and (Tuesday) 9 June. Overall the practice is rated as inadequate.
“Specifically, we found the practice inadequate for providing safe, effective, caring, responsive services and being well led.
“It was also inadequate for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).”
Professor Field said that Goodwood Court was breaking the law governing the safe care and treatment of patients, safeguarding patients from abuse and improper treatment, handling complaints, staffing and employing fit and proper people.
He said: “Our key findings across all the areas we inspected were as follows
- Patients were at serious risk of harm because the practice had not provided sufficient suitably qualified staff to meet their needs.
- Patients were at serious risk of harm because systems and processes were not in place to keep them safe. For example, appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control practice had not been taken.
- Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.
- Medicine management practices were unsafe and placed patients at serious risk of harm. This included requests for prescriptions. These had not been processed in a timely manner to ensure patients had access to their medicines.
- Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
- Urgent appointments were usually available on the day they were requested. However patients said that they had to wait a long time for non-urgent appointments and that it was very difficult to get through to the practice when phoning to make an appointment. Patients often experienced long delays when waiting to be seen by the GP.
- The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
“If the provider had continued to be registered with the Care Quality Commission, this location would have been placed into special measures. The areas where the provider must have made improvements are
- Ensure staffing levels are sufficient to meet the needs and size of the patient group.
- Ensure safe medicine management systems are in place to protect patients.
- Take action to address identified concerns with infection prevention and control practice.
- Ensure recruitment arrangements include all necessary employment checks for all staff.
- Ensure all staff is supported by means of supervision and appraisal.
- Ensure audits of practice are undertaken, including completed clinical audit cycles.
- Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
- Ensure systems are in place to respond to the concerns and complaints raised by patients and other stakeholders.
- Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
“On the basis of the concerns identified at this inspection we took enforcement action.
“The CQC applied for and were granted an urgent order to cancel the registration of the provider.
“This was subject to appeal by the provider in the First Tier Tribunal. An initial appeal was made but subsequently withdrawn. The order stands and the provider’s registration has been cancelled.
“As part of this action CQC liaised with NHS England to ensure measures were put in place to provide support, care and treatment for the patients affected by this closure.
“Patients previously registered with Goodwood Court Medical Centre were transferred to another local practice.”
Charter Medical Centre, a few hundred yards away, has taken over the Goodwood Court list.
Andy Watts, the GP in charge of Goodwood Court, has been referred to the General Medial Council (GMC). Dr Watts is still able to practise but with restrictions.
The other partner, Abubakr Osman, had not been at work for some time when the inspection took place. Dr Osman has also been referred to the GMC and placed under restrictions.
To read the full CQC inspection report, click here.