The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Ajit Pratap Mehrotra Also known as Windsor Medical Centre

Overall: Inadequate read more about inspection ratings

Windsor Medical Centre, 2 William Street, Leeds Road, Dewsbury, West Yorkshire, WF12 7BD (01924) 465699

Provided and run by:
Dr Ajit Pratap Mehrotra

All Inspections

13 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Ajit Pratap Mehrotra on 13 January 2016. Overall the practice is rated as inadequate.

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

  • Not all incidents and significant events had been reported and investigated.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the clinical skills, knowledge and experience to deliver effective care and treatment. However, staff had not been provided with up to date mandatory training.
  • There was no single patient record system as the practice used a combination of electronic and paper clinical records.
  • Controlled drugs were stored securely and accurate records kept from 2016. However there were gaps in previous records.
  • Risks to patients were were not assessed and well managed. For example, health and safety and legionella risk assessments had not been undertaken.
  • Information about services and how to complain was available and easy to understand.
  • Data showed patient outcomes were varied compared to the locality and nationally.
  • Although some themed reviews had been undertaken, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • 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.
  • Data from the national GP patient survey showed 100% said they found the receptionists at the practice helpful.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had a number of policies and procedures to govern activity, but some were out of date and it was evident some policies were not being implemented by the practice.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Establish governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
  • Ensure that staff have up to date professional registration and indemnity.
  • Provide staff with appropriate up to date practice specific policies to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice and local CCG.
  • Ensure that staff participate in mandatory training.
  • Securely maintain accurate, complete and contemporaneous patient records.
  • Ensure there is a process in place for undertaking criminal record checks at the appropriate level for clinical staff.
  • Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
  • Ensure quality improvement activities such as clinical audits are undertaken to improve patient outcomes.
  • Ensure staff who act as chaperones receive training and understand the role.
  • Ensure confidential waste is stored securely for disposal.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 December 2013

During a routine inspection

As part of our inspection we spoke with two people who used the service, a GP, the practice manager, a practice nurse and two reception staff.

During our visit we heard staff speaking to people in a respectful manner. Staff told us should someone visiting the practice wish to speak in private they would respect the person's wishes and take them to a private room. This was an example of how people's privacy and dignity were respected.

Appointments were provided by a multidisciplinary team of staff and these included a GP, practice nurse and midwife. People who used the service told us they had found it easy to make an appointment with the GP and practice nurses.

The provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.