This practice is rated as Good overall. (Previous rating June 2017 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Rajesh Pandey on 07 August 2018. Dr Rajesh Pandey came out of special measures in June 2017. This inspection was carried out as part of our programme to ensure that improvement is sustained in practices that have come out of special measures.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• The practice ran an open surgery every morning ensuring that any patient that wanted to see a clinician could do so.
• Following a practice initiative they had decreased the prescribing of opioid (strong, potentially addictive pain killers) medicines in appropriate patient groups by 42%.

• The practice had been running a substance misuse clinic for more than five years which was run fortnightly by a clinician from a local specialist team.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure care and treatment is provided in a safe way to patients.

Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

Review and implement appropriate advice on the appointment of fire marshals.

Review and improve the system for updating protocols and registration checks..

Review and improve uptake of childhood immunisations.

Review and improve how the medicines reviews are reflected within the clinical system.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Rajesh Pandey on 8 December 2015. The practice was rated as inadequate overall and in safe, well-led and requires improvement in effective and responsive and good in caring. We issued warning notices against Regulation 11 (Need for consent), Regulation 12 (safe care and treatment), Regulation 17 (good governance), and Regulation 19 (fit and proper persons employed). We undertook a focused follow up inspection on 6 April 2016 to check progress against the warning notices and saw evidence of improvements. A second comprehensive inspection was undertaken on 31 August 2016. The practice was rated as good in all domains and overall. 

During this inspection we noted many areas of significant improvement in patient care.

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

• The practice had taken action to address risks and make improvements. Improvements were seen in recruitment, infection control, engagement with patients, fire safety, the use of equipment and the management of incidents.
• Improvements were seen in relation to the management of medicines.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. There was evidence of discussion and learning, however the system was still being embedded and evidence of reviews was limited.
• There was evidence of patients receiving an apology when things went wrong and a patient apology template was available. 
• Data showed patient outcomes were comparable to the national average. There was evidence of audits being carried out to drive improvements to patient outcomes.
• Staff generally had training and appraisals with personal development plans to support them to carry out the duties of their roles and we saw improvements in this area. There was evidence of clinical staff training to improve patient outcomes and experience and the practice manager had commenced a practice management course. However, one member of staff had received no mandatory training and no appraisal.
• There was evidence of effective multi-disciplinary working and engagement with other services.
• Patients said they were treated with compassion, dignity and respect.
• The practice had taken action to improve engagement with patients through the development of a PPG (patient participation group). Improvements had been implemented as a result of this engagement. Action, including additional GP training had been taken by the practice to improve patient experience of GP consultations as a result of the national GP patient survey.
• The practice had a number of policies and procedures to govern activity, but they did not always reflect practice within the service.
• The practice had improved safeguarding training and had developed a child safeguarding policy. There was also a safeguarding vulnerable adult’s policy in place.
• The practice provided flexible appointments, including extended hours and walk in appointments.
• The practice had a complaints policy in place although there was no record of verbal complaints and only one written complaint that had been received by NHS England. Information for patients on how to complain was included in a patient information leaflet.
• There was evidence of improved communication and action taken as a result of concerns raised.

The areas where the provider should make improvements are:

• Ensure that all significant events and complaints including verbal complaints and subsequent actions are recorded and reviewed and that all staff participate in the end to end process.
• Ensure that policies used are aligned with practice.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service and the hard work the practice had undertaken to make improvements following their previous inspection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a focused warning notice follow up inspection at Dr Rajesh Pandey on 6 April 2016 following an inspection on 8 December 2015 where the practice was rated as inadequate in safe and well-led and overall.

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

• There were improvements to the support staff received to enable them to fulfil the requirements of their role. For example mandatory staff training was in progress and annual appraisal and continuing professional development plans were in place. Staff with lead roles such as infection control had attended the relevant training to carry out this role.
• The GP had attended training in relation to joint injections although was not carrying these out at the time of our inspection. They had also developed protocols for obtaining consent and were planning to attend further training in records management to ensure continued improvements.
• The practice had made improvements to their recruitment policies and appropriate checks on staff had been undertaken. For example, all staff had received a disclosure and barring service (DBS) check and all clinical staff were checked to ensure their appropriate registrations were up to date.
• The practice had made improvements in relation to promoting cleanliness and hygiene and there were improved procedures in relation to infection control.
• Risk assessments had been carried out in relation to fire safety, infection control, control of substances hazardous to health (COSHH) and legionella. However, the practice had not yet carried out the recommended action following their legionella risk assessment.
• The practice had sourced appropriate emergency equipment for the practice including a defibrillator and oxygen. These were subject to appropriate regular check. The practice had also sourced basic life support training for all staff.
• The practice had improved their overall governance systems. For example regular staff meetings were being held where issues such as significant events and complaints were discussed. The practice had worked with external contractors and had sought expert advice in relation to improving fire safety, evacuation procedures and disability access within the practice.
• The practice was in the process of developing their patient participation group (PPG) and had their first meeting planned with four patients who had volunteered later in April.
• The practice had begun the process of clinical audit and had plans in place to develop these into full cycle audits over time.

The areas where the provider must make improvements are:

• Ensure that action taken as a result of the legionella risk assessment is completed in a timely way.

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 Rajesh Pandey on 8 December 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe services and being well led. It was also inadequate for providing services for all of the population groups. Improvements were also required for providing effective and responsive services. It was good for providing caring services.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice had not ensured systems and processes were established and operated effectively to prevent abuse of service users as staff were not up to date with safeguarding training and there was no internal safeguarding policy.
• Staff were not consistently supported to enable them to fulfil the requirements of their role. For example mandatory staff training was out of date in a number of areas, not all staff had received an annual appraisal and continuing professional development plans were not in place.
• The GP did not obtain written consent for invasive procedures such as joint injections and patients were not sufficiently informed of the risks or complications of the procedure and any alternatives.
• The practice did not have effective systems in place to ensure safe care and treatment for patients. For example, the practice did not have robust recruitment policies and procedures in place and appropriate recruitment checks on staff had not been undertaken. The practice had not undertaken DBS checks or a risk assessment on staff undertaking chaperone duties and joint injections were being carried out by a GP who had not received appropriate training. The practice did not ensure the surgery was adequately clean and comprehensive infection control procedures were not in place or carried out, including risk assessments for legionella, staff training and regular audit. The practice did not have a procedure in place for the control of substances hazardous to health (COSHH) and did not have relevant data sheets in place relating to this. There was no medicine management policy or cold chain procedure in place, medicines and blank prescriptions were not stored securely and there was not an adequate system in place to manage high risk medicines. The practice could not demonstrate they were equipped for dealing with emergencies as they did not have oxygen and basic life support training was out of date.
• The practice did not have in place good governance systems. For example there was not a comprehensive system in place for appropriate environmental risk assessment such as fire safety and evacuation, disability access, use of equipment and not having emergency oxygen or a defibrillator on site. The practice did not have a system in place to ensure appropriate policies were available to staff and where policies were available they were not consistently reviewed and updated. The practice did not have a patient participation group (PPG) in place and had not acted on the results of the national GP patient survey that showed a lower than average score in terms of GP consultations. Staff were not clear about reporting significant events and there was limited evidence of significant event analysis, learning and communication with staff. There was no evidence of the practice having a comprehensive audit plan in place.
• The practice achieved an overall QOF (quality and outcomes framework) score relating to patient outcomes that was in line with local and national figures.
• 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 via a walk in clinic and patients were generally able to access non-urgent appointments within a week.

The areas where the provider must make improvements are:

• Ensure that staff are up to date with safeguarding training and that there are appropriate safeguarding policies, procedures and practices in place.
• Ensure that mandatory staff training is up to date in all areas, that all staff receive an annual appraisal and that continuing professional development plans are in place.
• Ensure that written consent is obtained for invasive procedures such as joint injections and patients are sufficiently informed of the risks or complications of the procedure and any alternatives.
• Ensure robust recruitment policies and procedures are in place and appropriate recruitment checks on staff are undertaken prior to recruitment.
• Ensure that DBS checks or a risk assessment is carried out on staff undertaking chaperone duties and that GPs are appropriately trained to carry out clinical procedures.
• Ensure the surgery is adequately clean and that comprehensive infection control procedures are in place and carried out, including risk assessments for legionella, staff training and regular audit.
• Ensure there is a procedure in place for the control of substances hazardous to health (COSHH) and that relevant data sheets are in place relating to this.
• Ensure that a medicine management policy and cold chain procedure are in place, that medicines and blank prescriptions are stored securely and that there is an adequate system in place to manage high risk medicines.
• Ensure that the practice is equipped for dealing with emergencies by ensuring oxygen is available and that staff have up to date basic life support training.
• Ensure there is a comprehensive system in place for appropriate environmental risk assessment such as fire safety and evacuation, disability access, use of equipment and not having emergency oxygen or a defibrillator on site.
• Ensure that appropriate policies are available, reviewed and updated in line with local and national guidance.
• Ensure that a patient participation group (PPG) is in place and that results of the national GP patient survey are acted on, particularly in relation to lower than average scores in terms of GP consultations.
• Ensure staff are clear about reporting significant events and that significant event analysis, learning and communication with staff takes place.
• Ensure there is a comprehensive audit plan in place to drive improvements in patient outcomes.

The areas where the provider should make improvement are:

• Ensure that chaperone notices are visible in consulting and treatment rooms.
• Ensure that patients are appropriately screened for dementia in line with national guidance.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of 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 to varying the terms of their registration within six months if they do not improve. The practice 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 by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice