Archived: Dr Jaswant Rathore Also known as Castle Meadows Surgery

Updated 7 March 2018

Dr Jaswant Rathore is registered with the Care Quality Commission (CQC) as a single-handed provider and is located in the town of Dudley. The practice is also known as Castle Meadow Surgery and the provider holds a General Medical Services contract with NHS England. A GMS contract is a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract. The practice is a member of the NHS Dudley Clinical Commissioning Group (CCG). The CCG confirmed that the GMS contract is with three partners at the practice and the CQC registration was in the process of being updated at the time of the inspection.

The practice is situated in a purpose built single storey premises owned by Dr Rathore. The practice provides one treatment room and four consulting rooms. The practice has limited car parking facilities available with allocated spaces and access for those patients with a disability.

The practice staffing comprises:

• One full-time GP partner (female).
• Three salaried GPs (female) working a combined total of 17 sessions per week (plus locum GPs providing cover for maternity leave).
• One GP registrar (male) working five sessions per week.
• Two practice nurses working a combined number of sessions equal to one whole time equivalent (WTE).
• A practice managing partner.
• A practice manager for information technology, health and safety and governance.
• An assistant practice manager.
• A medical secretary.
• A team of five reception staff and an apprentice.

At the time of the inspection the practice had 5,894 registered patients. The practice area has overall average levels of deprivation when compared with local and national averages with pockets of deprivation. The population distribution is broadly in line with local and national averages.

The practice is open from 8am to 6.30pm each week day. Routine appointments can be booked in person, by telephone or on-line. Home visits are available to patients with complex needs or who are unable to attend the surgery. When the practice is closed patients can access the out of hours service provided by Malling Health by calling 111 and there is an urgent care centre at Russells Hall Hospital.

Consulting times with a GP are available in the morning from 8am to 11.30am each week day. Afternoon appointments are available from 2.30pm to 6.30pm on Mondays and Wednesdays and from 4pm to 6.30pm on Tuesdays, Thursdays and Fridays. The nearest hospital with an A&E unit and a walk in service is Russells Hall Hospital.

Further details about the practice can be found by accessing the practice’s website at www.castlemeadowssurgery.nhs.uk

Updated 7 March 2018

We previously carried out an announced comprehensive inspection at Dr Jaswant Rathore on 21 July 2015. The overall rating for the practice was good, however the rating for providing safe services was requires improvement. This was due to the lack of assessment for emergency equipment required and for incomplete recruitment checks on staff acting as a chaperone. The full comprehensive report on the 21 July 2015 and the follow up report on 4 October 2016 inspection can be found by selecting the ‘all reports’ link for Dr Jaswant Rathore on our website at www.cqc.org.uk.

Following the comprehensive inspection on 21 July 2015, we carried out a focused desk based inspection on 4 October 2016 to confirm that the practice had carried out their plan to meet the requirements identified in our comprehensive inspection on 21 July 2015. We continued to rate the practice Good overall and the rating for providing safe services had improved to Good.

We carried out an announced focused inspection on 6 February 2018 to review the arrangements for providing safe and well-led services following the conviction of Dr Jaswant Rathore on 17 January 2018 and the custodial sentence imposed on 18th January 2018.

Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• The reporting and recording of significant events detailed concerns identified and were appropriately followed up to prevent further occurrences and ensure improvements made where appropriate.
• Arrangements were in place for sharing external best practice guidance and the learning outcomes from significant events, incidents and near misses with staff.

• The practice had systems to keep patients safe and safeguarded from the risk of abuse however, the safeguarding policy for vulnerable adults did not reflect the most up to date guidance.

• The practice had a child protection register and alerts were placed on the clinical system to identify children at risk. A protocol was in place to monitor and follow up children who did not attend hospital appointments. Vulnerable adults were highlighted on the clinical system.

• Infection control audits and action plans had been completed to promote a clean and appropriate environment.

• Staff recruitment checks did not meet legal requirements.

• Staff had clear roles and responsibilities but not all staff had received role specific training.

• The practice had started to improve their governance arrangements; however there were gaps in the practice’s governance systems and processes.

The areas where the provider must make improvements are:

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

• Ensure specified information is available regarding each person employed.

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

For details, please refer to the requirement notices at the end of this report.

The areas where the provider should make improvements are:

• Ensure the safeguarding policy for vulnerable adults reflects current guidance on the categories or definitions of the types of abuse for example, modern slavery.

• Provide patients with information of the chaperone service on the practice website and review the practice chaperone policy.

• Introduce an attendance register for staff.

The service will be re-inspected within 12 months of the registration being updated.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 7 March 2018

Updated 7 March 2018

Updated 7 March 2018

Updated 7 March 2018

Updated 7 March 2018

Updated 7 March 2018