The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Jaswant Rathore Also known as Castle Meadows Surgery

Overall: Requires improvement read more about inspection ratings

100 Milking Bank, Dudley, West Midlands, DY1 2TY (01384) 234737

Provided and run by:
Dr Jaswant Rathore

All Inspections

6 February 2018

During an inspection looking at part of the service

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

4 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of Dr Jaswant Rathore’s practice, at Castle Meadows Surgery, in July 2015. While no breaches of legal requirements were found, the practice was rated as requires improvements for providing safe services. This was because we identified some areas where the provider should make improvements.

We carried out a focussed desk based inspection of Dr Jaswant Rathore’s practice, at Castle Meadows Surgery on 4 October 2016 to check that the provider had made improvements in line with our recommendations. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Jaswant Rathore on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:

  • Since our comprehensive inspection in July 2015, the practice had reviewed risk applied for disclosure and barring (DBS) checks as required, for some non-clinical staff members including those who chaperoned.
  • The practice had adequate arrangements in place to manage in the event of a medical emergency. Following our inspection, the practice ensured they were equipped to respond to medical emergencies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Castle Meadows Surgery on 21 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing effective, caring, responsive and well-led services. It was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people; people whose circumstances may make them vulnerable and people experiencing poor mental health. It required improvement for providing safe care.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • We saw a number of risk assessments and plans in place with regards to the absence of emergency equipment such as oxygen and the absence of Disclosure and Barring Service checks (DBS checks) for those who chaperoned.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed.
  • Information about services and how to complain was available and easy to understand.
  • There was a clear leadership structure and staff felt supported by management. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • The practice was continuing to attract new patients and to help with this the practice had plans in place to move to larger purpose-built premises. We noticed carpet was in place within the room used to perform minor surgery. The practice explained how the move would help to provide a bigger waiting room to cater to all patients during busy periods and to provide more suitable rooms for clinical staff to carry out consultations and treatments such as minor surgery.
  • The practice was above average across areas of the quality outcomes framework (QOF) for 2014 and the practice was above average on results from the national gp patient survey, published in July 2015. 100% of the respondents described their overall experience of the practice as good. The practice was also above average for its satisfaction scores on consultations with doctors and nurses.

We saw an area of outstanding practice:

  • The practice had a patient services team in place; this was a unique service consisting of a patient services manager and two coordinators. The team provided a personal assistant service for patients to discuss things like tests results and referrals with a named manager or co-ordinator in the practice. Patients who contacted the practice with concerns or queries were put through to the patient services department which improved phone-line access for those wishing to book appointments. Staff told us that this was a contributing factor in the success of their telephone access. The patient survey information we reviewed showed that 99% of the respondents said they found it easy to access the surgery by phone, compared to the CCG average of 68% and national average of 73%.

However there were areas of practice where the provider should make improvements:

  • Ensure risk assessments are robust with regards to the absence of emergency medical equipment
  • Ensure DBS checks are completed for those staff who are left alone with patients when acting as a chaperone

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice