The Surgery Also known as Dr Raman Chandel and Partner

We carried out an announced inspection at The Surgery on 22 July 2022. Overall, the practice is rated as Requires improvement.

Safe - Requires improvement

Effective - Requires improvement

Caring – Good

Responsive - Good

Well-led - Good

This location was previously registered under a different provider. We inspected the practice under the previous provider registration on 28 April 2016:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to:

• Inspect and rate all key questions

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
• Requesting staff complete questionnaires
• Requesting the practice signpost patient to our website to complete ‘Give Feedback on Care’ forms for this service.

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 Requires Improvement overall

We found that:

• There were systems in place to keep patients safe and protect them from avoidable harm. However, some of these required strengthening.
• The system for recording staff vaccination status was ineffective.
• There were a lack of medication reviews taking place.
• There was a stock of emergency medicines held and systems in place to check they were in date. There was no risk assessment for what medicines should and should not be held.
• Where patients had undergone monitoring tests these were not always reflected in the patient records. In some cases, the patient’s medication condition had not been coding.
• There were systems in place for assessing/auditing risk. However, when issues were identified, there was not always an action plan in place to address this.
• Data for the practice uptake for childhood immunisations was lower than target for four out of five childhood immunisation indicators.
• Data for uptake of cervical screening showed the practice had met the minimum target.
• Most patients received effective care and treatment that met their needs. However, not all patients with a long-term condition received timely review.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had identified less than one percent of their patient population as carers.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• There was an open culture at the practice and staff worked as a team.
• There were overarching governance structures in place, however some of these required further strengthening to ensure they were fully effective.

We found one breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

In addition, the provider should:

• Continue to identify carers from their patient population.
• Continue to improve uptake for childhood immunisations.
• Improve the accuracy of coding within patient records.
• Develop a protocol for recording on the patient record their test results.

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