Archived: Dr Rajan Mohile Also known as Chadwell Medical Centre

Updated 4 May 2017

Dr Rajan Mohile, also known as Chadwell Medical Centre is situated in Grays in Essex. It provides GP services to approximately 5000 patients living in Chadwell St. Mary and Tilbury.

The practice holds a Personal Medical Services contract (PMS) with the NHS. This contract is being terminated at the end of March 2017. The practice is registered with the Care Quality Commission as an individual provider. The lead GP is supported by another male GP who is a partner to the NHS contract, a female long-term locum GP, a part-time practice nurse and a part-time healthcare assistant.

The practice population has a slightly lower number of children aged 0 to 4 years than the England average. It has more patients aged over 65 years and over 75 years. Economic deprivation levels affecting children and older people are significantly higher than average and unemployment levels are lower. The life expectancies of men and women are lower than the local average by one year. There are a higher number of patients on the practice’s list who have long standing health conditions. The local area is on the more deprived decile on national indicators, which may indicate a higher demand for services.

Administrative support consists of a part-time practice manager as well as an assistant practice manager, a head receptionist and a number of reception and administrative staff.

The practice is open from 8am until 6.30pm every weekday. Appointments are available with a GP or nurse from 9:00am to 10:30am in the morning and from 4:30pm to 6:30pm, Monday to Friday.

The practice has opted out of providing 'out of hours’ services which is now provided by Integrated Care 24, another healthcare provider. Patients can also contact the NHS 111 service to obtain medical advice if necessary. Patients could attend the Health Hub at Tilbury Health Centre on a Saturday and Sunday morning for pre-bookable appointments with a GP or nurse.

Updated 4 May 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Rajan Mohile, also known as Chadwell Medical Centre on 21 March 2016. The overall rating for the practice at that time was inadequate. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Dr Rajan Mohile on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection following a rating of special measures carried out on 31 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 31 March 2016. As this was a comprehensive inspection following a rating of special measures, we revisited all key questions and population groups as well as following up on the previous breaches of regulation identified.

We carried out an announced comprehensive inspection at on 31 January 2017. Overall the practice is rated as inadequate.

Our key findings were as follows:

• Although significant events were reported and recorded, learning was not implemented and patients were at risk.
• The practice did not act upon MHRA alerts.
• Data showed some patient outcomes were low compared to the locality and nationally. There had been little or no improvement since our previous inspection.
• Steps had been taken to monitor patients taking some high risk medicines, as identified by our previous inspection. However, not all patients taking high risk medicines were being effectively monitored to ensure their medicines were prescribed at the correct and safe dosage.
• Not all referrals were made in a timely manner. Opportunities to physically examine patients who were at risk were missed.
• Although some administrative audits had been carried out, these had not identified and rectified all serious risks.
• Staff carrying out chaperone duties now had a DBS check in place to assess their suitability for the role.
• Patients continued to praise staff, but there was concern with the availability of GP appointments. There was a two week wait for routine appointments with the GP.
• Feedback from the GP survey was below national and local averages in respect of access to the practice, and in line with averages in relation to care and treatment by the clinicians.
• The practice was not pro-active in supporting patients to live healthy lifestyles and systems in place to recall patients for health checks and reviews were not robust.
• Effective improvements had not been implemented.
• There was now a legionella risk assessment in place.
• Information about services and how to complain was available and easy to understand.
• Patients’ records were still incomplete. There had been seven significant events relating to incomplete patient records in the last year, but effective learning had not been implemented.
• There had been no improvement which sought to ensure that all clinicians were keeping up to date with and implementing NICE guidelines. We found evidence where NICE guidelines were not being followed in relation to diabetes checks.
• Measures had been put in place to monitor prescription stationery.
• There continued to be insufficient nursing provision.
• Nurses were not using the most up to date Patient Group Directions (PGDs) to authorise them to administer vaccines safely. These were not all signed.
• Care plans were either incomplete or not being used.
• There were not effective procedures in place to recall patients for cervical screening. The practice did not follow up children who did not attend for their vaccinations.
• The practice had identifies 54 patients as carers which amounted to 1% of the practice population.
• The practice was in the process of having their contract terminated with NHS England and did not have a vision or a strategy.

As a result of the findings at this inspection, we considered enforcement action against the provider and extending their period of special measures. However, shortly after the inspection the provider applied to de-register all regulated activities with the Care Quality Commission. A new provider is in the process of being identified by the Clinical Commissioning Group with effect from 1st April 2017 and the practice will receive their support to manage and reduce the risks identified at this inspection, so that the risks to patients are managed.

Had the provider continued to be registered with the Care Quality Commission, we would have issued the provider with requirements notices to make the following improvements; :

• Implement a system to receive, action and respond to safety alerts.
• Review and monitor patients taking all high risk medicines.
• Improve the system for referrals.
• Ensure actions resulting from significant events are implemented to prevent reoccurrence.
• Put in place a robust system of quality improvement including clinical and non-clinical audit.
• Ensure nurses are working with signed, up to date PGDs.
• Put in place up to date care plans for patients experiencing poor mental health.
• Take steps to act on patient feedback raised in the National GP Patient Survey.
• Improve the systems to recall patients to their routine checks and appointments and put systems in place to encourage and advise patients on a healthy lifestyle.
• Ensure all patient records represent a complete and accurate picture of their medicines and attendances at the practice.
• Increase nursing provision.
• Implement systems to ensure clinicians are working in line with NICE and other best practice guidance.

In addition the provider should:

• Improve uptake for health checks for patients with learning disabilities.

This service was placed in special measures on 16th June 2016. Insufficient improvements have been made such that there remains a rating of inadequate for effective and well-led. Further risks identified have now resulted in safe being rated as inadequate. The practice therefore remains as inadequate overall and also remains in special measures for a further period of six months.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 4 May 2017

The practice is rated as inadequate for providing safe, effective, and well led services. It is rated good for providing caring services, and requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, examples of good practice.

• Nationally reported data showed that outcomes for patients with long-term conditions was worse for the monitoring of diabetes. There had been improvements in relation to asthma and hypertension.
• Referrals to other healthcare providers were not always effective.
• There was inadequate nursing provision which meant that people with long-term health conditions were not always have their health checks done.
• Patients on high risk medicines commonly used in this population group were now being reviewed effectively prior to receiving repeat prescriptions. However, this was not the case with all medicines that required monitoring.
• The practice worked with community nurse specialists in the on-going management of patients with long-term conditions.

Updated 4 May 2017

The practice is rated as inadequate for providing safe, effective, and well led services. It is rated good for providing caring services, and requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, examples of good practice.

• There were no systems to follow up children who persistently failed to attend for their vaccinations.
• Parents that we spoke with told us that they were always able to get an appointment for their child in an emergency.
• The practice worked closely with midwives and health visitors. A midwife a held a weekly clinic at the practice.
• Staff were aware of Gillick competence in relation to children under the age of 16 attending the practice without a parent or guardian.

Updated 4 May 2017

The practice is rated as inadequate for providing safe, effective, and well led services. It is rated good for providing caring services, and requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, examples of good practice.

• Patients taking high risk medicines commonly used in this population group were now being reviewed effectively prior to receiving repeat prescriptions. However, this was not the case with all medicines that required monitoring.
• The practice visited a local care home on a weekly basis to see patients registered with the practice. Other appointments could be made as the need arose. However, records at the practice were not consistently updated after these visits.
• There were regular meetings with other professionals to identify and manage older patients.

Updated 4 May 2017

The practice is rated as inadequate for providing safe, effective, and well led services. It is rated good for providing caring services, and requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, examples of good practice.

• The practice’s uptake for the cervical screening programme was 64%, which was lower than the national average of 82%.
• Weekend appointments were available at the Tilbury health hub for patients who could not access the surgery during working hours.
• The practice offered online services, such as prescription requests. There was a text message reminder service for routine health checks.
• An immunisation service was available for patients to access, although nurses did not have up to date, signed patient group directions available to support the administration of vaccines.

Updated 4 May 2017

The practice is rated as inadequate for providing safe, effective, and well led services. It is rated good for providing caring services, and requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, examples of good practice.

• Data available to us reflected that the practice was considerably below the local and national average for people with poor mental health, although there had been improvements in relation to patients experiencing dementia.
• The practice manager had conducted an audit of patients with dementia to ensure that they had a care plan in place.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive, agreed care plan documented in the record was 23%, which was significantly lower than the England average of 89%.
• There were 46 patients on the mental health register, none of which had a care plan.
• Patients taking high risk medicines commonly used in this population group were not being reviewed effectively prior to receiving a repeat prescription.

Updated 4 May 2017

The practice is rated as inadequate for providing safe, effective, and well led services. It is rated good for providing caring services, and requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, examples of good practice.

• The practice no longer provided health checks for patients with learning disabilities, and directed these patients to the local hub.
• Carers were identified and the practice informed vulnerable patients about how to access
• various support groups and voluntary organisations.
• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.
• Staff knew how to recognise signs of abuse in vulnerable adults and children.