We carried out an announced comprehensive inspection at Dr PV Gudi and Partner on 5 March 2019 as part of our inspection programme.

The practice was rated as requires improvement for the safe and effective key questions and requires improvement overall at the previous inspection in January 2018. You can read the report from our last comprehensive inspection on 18 January 2018; by selecting the ‘all reports’ link for Dr P V Gudi and Partner on our website at www.cqc.org.uk.

This report covers our findings in relation to improvements made since our last inspection and any additional improvements we found at this inspection. The report covers our findings in relation to all five key questions and six population groups.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good for all population groups and good overall, except for the safe key question which we have rated as requires improvement.

We rated the practice as requires improvement for providing safe services because:

• The system for learning from incidents and significant events had been implemented to ensure all staff were aware of the actions taken. However, we found there was a lack of understanding with the staff of what constituted a significant event and inconsistency in the recording of these.
• On reviewing the completed training schedule for staff, we found some of the clinical team had not completed the practice’s mandatory training schedule. This included infection prevention, fire and health and safety training. Since the inspection we have received confirmation that training had been completed.
• The practice was unable to demonstrate that some of the clinical staff had received immunisations that were appropriate their role. Since the inspection we have received evidence to confirm that the relevant blood tests and immunisations have been given.
• The practice had not followed their recruitment procedures and had not ensured that all the relevant checks were carried out prior to employment. This included: Evidence of conduct in previous employment. Since the inspection we have received confirmation that the appropriate checks have been completed.

We rated the practice as good for providing effective, caring, responsive and well led services because:

• The practice had reviewed their current appointment system and had increased the length of appointment times for one of the clinical team to ensure waiting times were reduced for patients attending appointments.
• Systems and processes had been introduced to ensure patients with long term conditions were monitored and reviewed appropriately.
• The practice continued to identify carers and had seen an increase in the number of carers on the practice register.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider should make improvements are:

• Review current processes for the recording of significant events to ensure they are relevant and all staff have a clear understanding of what constitutes a significant event.
• Continue to gather patient feedback to improve satisfaction scores for consultations with GPs.
• Continue to monitor staff immunisation status to ensure records are up to date.
• Review the current processes for monitoring of staff training to identify gaps in staff updates relevant to their role.
• Formally assess the need for a hearing loop to ensure that reasonable adjustments are made for patients where needed.
• Continue to identify carers to offer them support where needed.
• Ensure the relevant checks are completed for employing new members of staff.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection of October 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) – Requires improvement

We first inspected, Dr PV Gudi and Partner’s practice on 17 and 19 January 2017 as part of our comprehensive inspection programme. The overall rating for the practice was inadequate and the practice was placed into special measures. A second comprehensive inspection was carried out on 4 October 2017 where we found the practice had implemented some actions to mitigate the risks previously identified, however risks were still evident and the practice remained in special measures. The full comprehensive report for January 2017 and October 2017 inspections can be found by selecting the ‘all reports’ link for Dr Gudi and Partner on our website at www.cqc.org.uk. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.

This inspection, was an announced comprehensive inspection, carried out on 18 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspections. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

• The practice was in the process of reviewing their current processes for the management of patients with long term conditions and we saw evidence to confirm improvements had been made, however results were still low in comparison to local and national averages.
• The practice had systems to manage risk so that safety incidents and significant events were less likely to happen, however a review of the current process was required to ensure a better understanding of lessons learnt from an incident was shared with the team.
• The practice had implemented a programme of clinical audits to monitor services and demonstrated quality improvement.
• Staff understood their responsibilities to raise concerns, incidents and near misses and practice reported all events to the local clinical commissioning group through web based incident reporting and risk management software.
• The practice had implemented systems to ensure the effective management of patients on high risk medicines. We found patients who required closer monitoring, were being reviewed in line with prescribing recommendations.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice ensured that care and treatment was delivered according to evidence- based guidelines. They worked with a range of health and care professionals in the delivery of patient care.
• Clinical staff had attended training sessions on how to fully utilise the clinical system to ensure patients’ on clinical registers were being coded appropriately.
• The practice had previously implemented improvements to manage waiting times to be seen by the GP. Increased satisfaction had been reflected in patient feedback through the national patient survey. However, at this inspection patients comments received highlighted continued concerns around waiting times when attending the surgery for their appointments.
• There was a clear leadership structure and staff felt supported by management.

The areas where the provider should make improvements are:

• Review current appointment system to identify where improvements could be made to the waiting times of patients attending for their appointments.
• Review and consider patient feedback on staff attitude to identify areas for improvement. .
• Review current process for learning from incidents and significant events to ensure lessons learnt are shared with the team.
• Continue to monitor patients with long term conditions to ensure they are receiving the appropriate monitoring and reviews.
• Review how the practice could proactively identify carers in order to offer them support where appropriate.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr PV Gudi and Partner on 17 and 19 January 2017. The full comprehensive report of January 2017 inspection can be found by selecting the ‘all reports’ link for Dr PV Gudi and Partner on our website at www.cqc.org.uk. During the inspection, we found the practice was in breach of legal requirements and the overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. This was because appropriate processes were not in place to mitigate risks in relation to the safety and quality of the services offered. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.

This inspection was an announced comprehensive inspection, carried out on 4 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. We found some of risks had been mitigated and improvements had been made; however further breaches were identified and as a result of our inspection findings the practice is still rated as inadequate and remains in special measures.

Our key findings across all the areas we inspected were as follows:

• At the previous inspection we found the systems and processes in place to minimise risks to patient safety did not always operate effectively. This included infection control and management of emergency equipment and ensuring there were adequate supplies of medicines to deal with emergency situations. At this inspection we found these risks had been mitigated with the implementation of procedures to manage emergency equipment and medicines and monitor infection prevention.
• At the inspection in January 2017 clinical outcomes for a number of long term conditions and mental health were below the local and national averages. At this inspection we found the practice had started to review their current processes, however results were still low in comparison to local and national averages.
• At the previous inspection we found the service could not demonstrate effective management of patients on high risk medicines. At this inspection we found patients in receipt of prescriptions for medicines, which required closer monitoring, were not always receiving a review of their treatment in line with prescribing recommendations. Since the inspection we have received evidence to confirm that all patients on high risk medicines have been reviewed.
• At the previous inspection, coding errors were identified on patients’ records. We found at this inspection that the practice were not fully utilising the clinical system and there were errors on the clinical registers with patients being inappropriately coded. Since the inspection we have received assurances that training sessions have been organised to update the clinical team on the use of the clinical system.
• Since the last inspection the practice had addressed the support staff required in undertaking their roles and a new health care assistant had been recruited to support the practice nurse.
• The results of the latest national patient survey showed improvements on waiting times to be seen by the GP after their appointment time. This was an area of concern highlighted at the previous inspection in January 2017.
• During the inspection we found the practice was not thoroughly following systems and processes in relation to information governance and security. For example, consulting rooms were left unlocked, smart cards were left in the rooms and there was easy access to emergency drugs and patient information. Since the inspection we have received assurances that keypad locks have been added to each room.
• There was a clear leadership structure and staff felt supported by management.
• Staff understood their responsibilities to raise concerns, incidents and near misses and there was a system in place for reporting and recording significant events. From the sample of documented examples of recorded significant events we reviewed, we found there was an effective system for reporting and recording significant events and the practice reported all events to the local clinical commissioning group through web based incident reporting and risk management software. Investigations were discussed with the practice team to mitigate further risks.
• Arrangements were in place to safeguard children and vulnerable adults from abuse and local requirements and policies were accessible to all staff. Since the last inspection, all staff have received safeguarding training relevant to their role.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider must make improvements:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

There were also areas of practice where the provider should make improvements:

• Review how the practice could proactively identify carers in order to offer them support where appropriate.
• Review current processes for the collection of prescriptions to ensure practice policies are adhered too.
• Consider how to further encourage patients to attend annual reviews.

I confirm that this practice has not improved sufficiently and continues to be rated as inadequate overall and as a result remains in special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service. Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Dr Gudi and Partner offer a range of primary medical services from the Hill Top Surgery at 68 Hill Top, West Bromwich.

We found that the practice provided a safe, effective, caring, responsive and well led service. We found that there was a heavy reliance on the experience and expertise of the practice manager but that there were no contingency plans in place should the manager be away unexpectedly for any length of time.

Patients we spoke with were generally happy with the service they received at the practice, although some patients told us that it was difficult to get a routine appointment at short notice.

In advance of our inspection we talked to the local clinical commissioning group (CCG) and the NHS local area team about the practice. Neither of these organisations had any significant concerns about it.

We also examined patient care across the following population groups: Older people; those with long term medical conditions; mothers, babies, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health. We found that care was tailored appropriately to the individual circumstances and needs of patients in these groups.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr PV Gudi and Partner on 17 and 19 January 2017. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

• The systems and processes in place to minimise risks to patient safety did not always operate effectively. This included infection control and management of emergency equipment and medicines.

• Some patients’ needs were not assessed, reviewed and monitored in line with current evidence based guidance. This was reflected in records we reviewed and nationally published data. Clinical outcomes for a number of long term conditions and mental health were below the local and national averages.

• There was evidence of action being taken following clinical audit and data collection.

• Most patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

• Most patients said they found it easy to make an appointment with a GP and there was continuity of care. However, some patients had concerns about the “long” waiting time to be seen by the GP after their appointment time.

• The practice had governance arrangements in place to support staff in undertaking their roles. However, the arrangements for clinical governance and performance management were not always operated effectively.

• There was a clear leadership structure in place and most staff felt supported by the leadership.

• The practice had an active patient participation group and patient feedback was acted on to improve the service.

The areas where the provider must make improvement are:

Ensure systems and processes are established to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients which may arise from carrying on the regulated activity. Specifically:

• Ensure care and treatment is delivered in line with best practice and nationally recognised guidance. This includes operating effective recall systems to facilitate the health reviews of people experiencing poor mental health and people with long term conditions.

• Where quality and/or safety are being compromised the practice should respond appropriately, including taking timely action to address issues where they are raised. This includes improving clinical outcomes for patients and acting on patient feedback.

• Maintain securely up to date records concerning the management of the regulated activities and ensure the backlog of notes waiting summarising is completed as planned. In addition, records relating to the care and treatment of each person using the service must be fit for purpose.

The areas where the provider should make improvement are:

• Review staffing arrangements and ensure there is enough qualified staff to meet the needs of patients.

• Strengthen infection control practices to ensure mitigating action is implemented where improvements are identified to control the spread of infections.

• Equipment and medicines that are necessary to meet people's needs in a medical emergency should always be available in sufficient quantities and in date.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice