East Park Medical Centre - R P Pandya

We carried out an announced inspection at East Park Medical Centre - R P Pandya on 31 March 2022. Overall, the practice is rated as inadequate.

Set out the ratings for each key question

Safe - Inadequate

Effective – Inadequate

Well-led - Inadequate

Following our previous inspection on 19 January 2017, when we inspected the key question of safe the practice was rated Good overall and for the key question safe.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for East Park Medical Centre - R P Pandya on our website at www.cqc.org.uk

Why we carried out this inspection.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Leicestershire and Rutland. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit
• Conducting remote interviews with service users

Our findings

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 inadequate overall.

• The practice did not have clear systems and processes to keep patients safe.
• We found the practice did not appropriately maintain their safeguarding registers, the safeguarding policy was not comprehensive and staff had not completed training relevant to their role.
• Review of staff files showed gaps in recruitment practice and vaccination records were not in line with the current guidance when relevant to the roles undertaken.
• The practice had ineffective systems in place to ensure risks were mitigated in relation to the premises.
• The practice had ineffective systems and processes in place to manage and monitor infection control and cleanliness.
• On reviewing the staff training, we found some of the clinical and administration team had not completed the practice’s required training in line with their roles. This included infection prevention, fire safety, sepsis, cardiopulmonary resuscitation, major incident and health and safety training.
• The provider did not have appropriate systems in place for the safe management, supply, storage, checking and prescription of medicines. Emergency medicines were not readily available.
• On reviewing a sample of patients’ records we found systems and processes to manage the effective delivery of safe patient care were not robust. Patient reviews, assessments, medication reviews, management of high risk medications, unplanned admissions to hospital, patients with long term conditions and clinical coding was not always completed appropriately
• The provider was unable to show that staff had the skills, knowledge, competence and experience to carry out their roles. We found no evidence that staff had received regular reviews appraisals or audit of clinical practice.
• The leaders at the practice did not have full oversight of the challenges and risks to quality and patient care within the service.
• The practice was unable to provide evidence to show plans were in place to develop leadership capacity and skills, including planning for the future leadership of the practice.
• We found governance structures and systems were not robust to support safe and effective care. For example: processes to manage risks, staff training, patient health and medicines reviews were not effective.
• The practice had not developed a system to ensure service users had access to up to date information, the practice website did not contain current information.
• The provider was unable to demonstrate that clinical audit had a positive impact on quality of care and outcomes for patients. There was limited evidence of audits undertaken with no evidence of action provided to change practice to improve quality.

We found breaches of regulations. The areas where the provider must make improvements are:

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

For further information see the requirement notice and enforcement section at the end of this report.

The areas were the provider should make improvements are:

• Continue taking action to improve the uptake of national screening programmes such as cervical screening and monitor its impact.
• Consider the requirement to develop a formal targeted improvement plan to demonstrate actions taken and monitoring processes.
• Develop a clear set of vision and values with a supporting strategy.
• Take action to ensure all elements of good governance are consistently covered in staff meetings.
• Develop a system to ensure staff files are well organised and contain consistent, up to date information.

I am placing this service in special measures. Services 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 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 by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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