Archived: Dr Lalta Sachdeva

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Lalta Sachdeva on 5 May 2016.

The practice was rated as inadequate and was placed in special measures. Practices placed in special measures are inspected again within six months of publication of the last inspection report. If insufficient improvements have been made and a rating of inadequate remains 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.

Additionally, a breach of the legal requirements was found because systems and processes had not been established and operated effectively. As a result, the provider was not assessing, monitoring and improving the quality and safety of the services provided and mitigating the risks related to the health, safety and welfare of service users and others. Therefore, a Warning Notice was served in relation to Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 Good Governance. because;

Following the comprehensive inspection, we discussed with the practice what they would do to meet the legal requirements in relation to the breach and how they would comply with the legal requirements, as set out in the Warning Notice.

We undertook this announced focused inspection on the 12 October 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. The practice was not rated as a consequence of this inspection, as the practice is in special measures. It will be inspected again, with a view to assessing the practice’s rating when the timescale for being placed into special measures has passed.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by using the link for Dr Lalta Sachdeva on our website at:

http://www.cqc.org.uk/location/1-500922994/reports

The areas where the provider must make improvements are:

• Ensure that the systems and processes to assess, monitor and improve the quality and safety of the servicesthat minutes comprehensively record the discussion held, that the process for routinely monitoring how the practice sought consent is effective and that risk assessments, audits and random sample checks of patient records are monitored and reviewed in order to assess how effective they were.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Lalta Sachdeva on 5 May 2016. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because there were no systems and processes in place to keep them safe. For example, appropriate recruitment checks on staff had not been undertaken prior to their employment, medicine management issues and actions identified to address concerns with infection control practice had not been taken.

• The practice did not have formal systems to underpin how significant events, incidents and concerns should be monitored, reported and recorded. Information about safety was not used to promote learning and improvement. There were no formal arrangements for monitoring safety, using information from audits, risk assessments and routine checks.

• Staffing levels were at a minimum level, which had a significant impact when staff were absent, due to sickness or holidays. There was a lack of evidence to demonstrate that actions were being taken to address this.

• National guidance and professional guidelines were not always being used to promote best practice in the care and treatment provided.

• Staff we spoke with told us they felt supported however; there was no documentary evidence to support this. For example, a newly appointed member of staff had not been supported by a formal induction program and existing staff had not received regular appraisals.

• All staff had been trained in safeguarding procedures and a lead had been identified for both vulnerable adults and children.

• Data showed some patient outcomes were low compared to the locality and nationally.

• There was no evidence of two cycle clinical audits, in order to support quality improvement activity.

• Results from the National GP Patient Surveys in July 2015 and January 2016 indicated that patients scored the practice lower than average in relation to; GPs and nurses listening to them giving them enough time and treating them with care and concern. The practice scored higher than averagefor accessing the service and the manner in which reception staff treated them.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• Appointment systems were effective and patients received timely care when they needed it.

• There was a lack of appropriate or suitable governance systems and processes. This meant that the practice was not providing safe, effective caring or well-led services for their patients, nor were they assessing and monitoring those services.

• The provider was aware of the requirements of the duty of candour. However, there were no systems to ensure compliance with the duty of candour, which included support training for all staff on communicating with patients about notifiable safety incidents.

• The practice did not have a Patient Participation Group (PPG). Whilst they were advertising for new volunteers to establish a new PPG, the practice had not reflected or learnt lessons from the last PPG, in order to ensure the effectiveness of such a group and to ensure improvements were made to the services offered.

The areas where the provider must make improvements are:

• Ensure that information about safety is used to promote learning and improvement by ensuring there are formal arrangements for monitoring safety, significant events, incidents and concerns; using information from audits, risk assessments and routine checks.

• Ensure that national guidance and professional guidelines are used to promote best practice in the care and treatment provided.

• Ensure recruitment arrangements include all necessary employment checks for all staff. Including appropriate risk assessments being completed for all staff where Disclosure and Barring Service (DBS) checks are deemed unnecessary.

• Ensure that new staff to the practice receive an induction that is recorded and they are signed off as competent for the role. As well as, ensuring staff are provided with up to date policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

• Ensure that governance processes and procedures are implemented to establish an on-going programme of quality improvement activity, such as patient feedback, lessons learnt from the previous PPG and clinical audits, as well as audits of safety alerts which must be used to monitor quality and systems to identify where action should be taken.

• Ensure feedback is sought from patients in relation to the services provided at the practice and implement improvements where identified.

• Ensure that the structure of staff meetings inform staff about the safety and performance issues affecting the practice and enable staff to feedback about services to be provided in a timely manner. Ensure that minutes are recorded that reflect the discussion and any actions that follow, including an audit trail for completion.

In addition the provider should:

• Improve the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if required.

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