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Archived: Dr Shashi Arora Good Also known as Baring Road Medical Centre

The provider of this service changed - see new profile


Inspection carried out on 22 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shashi Arora’s practice (also known as Baring Road Medical Centre on 22 March 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events, although the policy for managing such issues lacked specific detail.

  • Risks to patients were assessed and well managed.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Information about services and how to complain was available and easy to understand.

  • Patients said they found it difficult to make an appointment with a named GP and that routine appointments were not always immediately available. However, there were urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on in some cases.

  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

  • The practice should ensure that all clinical staff have DBS checks. If non-clinical staff are not DBS checked then a risk assessment as to why this is not required must be in place.

  • The practice should review its appointments systems, and telephone answering service in line with feedback from patients that we spoke to, comment cards that we received and the national patient survey which said that telephone waits were long and appointments difficult to access.

  • The practice should consider reviewing it’s diabetes management processes to seek ways to improve its patient outcomes in this area against national figures.

  • The practice should ensure that the seats in the reception area are free from tears to ensure that they are not an infection control risk.

  • The practice should ensure that floor covering on stairs are firmly attached so that in future they do not become a trip hazard.

  • The practice should review it’s policies to ensure that they are thoroughly documented, specifically detailing how and when the policy should be used, and what actions should be taken. In particular the serious untoward events policy and fire prevention policies should be reviewed.

  • The practice should look into ways of better identifying carers.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 7 July 2014

During a routine inspection

Baring Road Medical Centre is a general medical practice in the London borough of Lewisham with a list of approximately 6,255 patients. The borough is characterised by relatively high levels of deprivation and is the 16th most deprived out of 326 local authorities in England. Life expectancy for both males and females is lower than the England average with early deaths due to heart disease, stroke and cancer.

We carried out an announced inspection on 7 July 2014. Our inspection team was led by a CQC Inspector, accompanied by two specialist advisors; a GP and a Healthcare Manager and an expert by experience. Before our inspection we reviewed a range of information we held about the practice from our Intelligent Monitoring System. We met with NHS England, NHS Lewisham Clinical Commissioning Group (CCG) and Healthwatch Lewisham and reviewed the information they gave to us. During our inspection we spoke with a range of staff including GP’s, nurses, a healthcare assistant and management and reception staff. We also spoke with patients and a representative from the practice’s patient participation group (PPG).

The practice was effective, caring, responsive and well-led. Improvements were required for the service to be safe. This was because disclosure and baring service (DBS) checks had not been undertaken for appropriate staff members, including non-clinical staff who are required to chaperone patients.

The practice had measures in place to protect and promote the safety of patients in their care. They had procedures for reporting, recording and learning from significant incidents. Staff completed safeguarding training and were aware of the processes to follow if they suspect a patient was at risk of harm. Vaccinations and other injectable medicines were stored correctly at the practice. Staff received infection control training and infection control audits were conducted. Staff were trained to deal with medical emergencies and emergency equipment and medicine was available.

Clinical staff attended weekly meetings to discuss complex medical cases and had access to up-to-date guidelines to ensure treatment was delivered in line with current best practices. The practice engaged in clinical audit to review services and to improve outcomes for patients. Staff received annual appraisal to review training needs and to promote further professional development. The practice had regular meetings with the wider multi-disciplinary team to develop integrated care pathways for their patients.

Patients considered that they are treated with dignity and respect by most staff at the practice. They described positive experiences with the care provided to them by clinical staff and that they were provided with relevant information and explanation about their treatment options.

Staff were aware of their responsibilities in assessing a patient’s capacity to make decisions about their care.

The practice met the needs of different population groups. For example, the practice had links with social services and community matron to provide holistic care for older people. Patients with long term conditions, people experiencing poor mental health and patients with learning disabilities were invited for annual reviews. Extended hour appointments were available weekly for patients unable to attend the practice in routine opening hours because of work commitments. The practice nurses offered immunisations to children and babies with good uptake rates.

There was a culture of discussion and learning at the practice and staff felt generally well supported by the management team. Patient feedback was gathered from the patient reference group (PPG) and patient surveys and there was evidence of improvements made to the service as a result of this feedback. The practice had a complaints policy and all complaints received in the previous year were reviewed at an annual meeting.  There was a contingency plan in place to manage any significant disruption to services.