Dr S Bassi & Associates Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. Previously, we found the service was in breach of legal regulation because the practice was not managing risks to patient safety in relation to clinical record keeping, medicine monitoring and cervical cancer screening.

At this assessment, the rating has changed to inadequate because we found little improvement in the areas previously identified as concerns and we found significant failings in relation to most of the quality statements under the safe key question.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider recorded significant events on the computer system. Staff we interviewed provided examples of significant events that had occurred and learning points. However, we found that there was no evidence from meeting minutes of shared learning across all staff members.

The service had received one complaint over the last year. There was evidence that the complaint had been resolved, and a response sent to the complainant. The complaint had been recorded in a complaints meeting. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong, and staff told us there was an open culture.

The provider worked with people and health system partners to establish and maintain safe systems of care. However, we identified issues with the monitoring system to follow-up 2-week wait referrals for suspected cancer. The provider relied on people to contact the practice if they did not receive their appointment instead of taking a proactive stance of contacting people to ensure they received their appointments. In addition, a patient we spoke to said when they were referred to a specialist, after the results they were not followed up by the GP for next steps. The patient had to call the practice to progress their care and treatment.

Our review of staff records showed that safeguarding training was not always up-to-date or at the appropriate level for specific roles. Vulnerable people were not managed appropriately as the service had a handwritten list of vulnerable patients kept at the reception area. However, these patients were not coded in the clinical computer system and therefore clinical staff would not be aware of any vulnerable patients during consultations. The provider could not evidence disclosure and barring services checks or risk assessments for non-clinical staff carrying out chaperoning duties.

Emergency equipment was available and maintained. However, the provider could not evidence basic life support training or sepsis training for all staff therefore we were not assured that all staff would be effective in the event of a medical emergency or in recognising the signs of a rapidly deteriorating patient.

The service did not always detect and control potential risks in the care environment. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. However, no infection prevention and control audit had been carried out and the business continuity plan did not contain all the necessary information, nor had the plan been reviewed to ensure continuity of essential services during disruptions.

The provider did not have processes in place to evidence staff recruitment, induction, training and appraisal. There were a range of clinical and non-clinical roles within the practice, and we found significant gaps in staff records.

We reviewed 4 staff records including a receptionist, the advanced nurse practitioner, the practice nurse and a sessional GP. We found no evidence of proof of identity for the practice nurse, no evidence of a disclosure and barring services check for the advanced nurse practitioner or the practice nurse, and no evidence of a disclosure and barring services check or an appropriate risk assessment for the receptionist. We found no evidence of references for any staff and no evidence of relevant qualifications for clinical staff. We found no induction records for any staff.

In addition, we found no evidence of training records for the advanced nurse practitioner, including no evidence of role-specific training undertaken. Safeguarding training for a receptionist was not at the appropriate level. There was no evidence of fire safety or infection control training for a sessional GP. Adult safeguarding training for the sessional GP was not at the appropriate level and there was no evidence available of Mental Capacity Act training for them. There was no evidence of health and safety training for all 4 staff. There was no evidence of training in learning disability and autism for 3 staff and no role-specific training records were available for the practice nurse.

There were no records to indicate any staff had received up-to-date annual appraisal and the practice manager confirmed they were overdue.

Staff told us that the gaps in staff records was because of a shared drive export failure from December 2024. We gave the practice 1 week following the site visit to provide us with the missing information however we did not receive it.

The service did not assess or manage the risk of infection adequately. The practice had a designated infection prevention and control lead and deputy. However, we found gaps in staff training and no infection prevention and control audit had been carried out. When we asked for an infection prevention and control audit we were given a pre-acceptance healthcare waste self-audit tool which covered waste management only. Following the assessment the provider ensured an infection prevention and control audit was undertaken and sent us the evidence.

We reviewed 4 staff records. There was no evidence of vaccination records or a risk assessment for a receptionist. There was evidence of hepatitis B status for the advanced nurse practitioner and a sessional GP however they were not up-to-date, and there was no evidence of any other routine vaccinations for these staff appropriate to their role. There was no evidence of any vaccination records for the practice nurse.

We noted that the premises were clean, and patients did not report any concerns about infection prevention and control. Patients said staff wore appropriate personal protective equipment and they had observed them carrying out hand hygiene.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen safely.

Data reviewed as part of our assessment showed that the service was performing in line with local and national averages for all prescribing indicators.

Our clinical searches identified a number of concerns relating to medicines:

We reviewed 5 older patients prescribed antiplatelet medicines and found that 3 of these patients were at risk of gastrointestinal bleed.

We identified 39 patients, each prescribed 10 or more medicines, without a medicine review in the last 18 months.

We identified 6 patients on a specific Disease Modifying Antirheumatic drug and found 2 of these patients had been prescribed the medicine without sight of recent blood tests.

We identified 8 patients on a specific Disease Modifying Antirheumatic drug and found 2 of these patients had been prescribed the medicine without sight of recent blood tests.

We identified 10 patients with heart failure prescribed a medicine without the required monitoring. We reviewed 5 of these patients and found 3 patients had been prescribed the medicine without sight of recent blood tests.