• Doctor
  • GP practice

Archived: Dr Samuel Bhasme Also known as The Surgery Railway Street

Overall: Inadequate read more about inspection ratings

The Surgery, 19 Railway Street, Gillingham, Kent, ME7 1XF (01634) 853667

Provided and run by:
Dr Samuel Bhasme

Latest inspection summary

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Background to this inspection

Updated 20 November 2018

  • The registered provider is Dr Samuel Bhasme.
  • Dr Samuel Bhasme is located at The Surgery, 19 Railway Street, Gillingham, Kent, ME7 1XF. The practice has a general medical services contract with NHS England for delivering primary care services to the local community. The practice website is .
  • As part of our inspection we visited Dr Samuel Bhasme, The Surgery, 19 Railway Street, Gillingham, Kent, ME7 1XF only, where the provider delivers regulated activities.
  • Dr Samuel Bhasme has a registered patient population of approximately 2,500 patients. The practice is located in an area with a higher than average deprivation score.
  • There are arrangements with other providers (Medway Doctors On Call Care) to deliver services to patients outside of the practice’s working hours.
  • The practice staff consists of one GP (male), one practice manager, one practice nurse (female) as well as reception and cleaning staff.
  • Dr Samuel Bhasme is registered with The Care Quality Commission to deliver the following regulated activities: diagnostic and screening procedures; family planning; maternity and midwifery services; treatment of disease, disorder or injury.

Overall inspection

Inadequate

Updated 20 November 2018

We carried out an announced comprehensive inspection at Dr Samuel Bhasme on 11 July 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After our inspection in July 2017 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out a second announced comprehensive inspection at Dr Samuel Bhasme on 20 March 2018. The overall rating for the practice remained inadequate and the practice was placed in special measures for a further period of six months. A Warning Notice was served in relation to breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 Good Governance, found at this inspection. The full comprehensive report on the March 2018 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After our inspection in March 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the Warning Notice.

We carried out an unannounced focussed follow-up inspection on 19 June 2018 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 20 March 2018. The practice was not rated as a consequence of this inspection.

As our inspection on 19 June 2018 found that the practice had not fully met the Warning Notice issued on 12 April 2018 and we therefore imposed conditions on Dr Samuel Bhasme’s registration with the Care Quality Commission. The conditions were:

Condition One: the registered person must not register any new patients at Dr Samuel Bhasme without the written permission of the Care Quality Commission unless those patients are newly born babies, or are newly fostered or adopted children of patients already registered at Dr Samuel Bhasme.

Condition Two: the registered person must submit to the Care Quality Commission, on a monthly basis, copies of significant events management and fire safety management action plans, including dates for completion of each action.

After the inspection in June 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was undertaken following the second period of special measures and was an announced comprehensive inspection carried out on 9 October 2018 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 inspections on 20 March 2018 and 19 June 2018. This report covers findings in relation to those requirements.

Overall the practice remains rated as inadequate.

The key questions are rated as:

Are services safe? – Inadequate.

Are services effective? – Inadequate.

Are services caring? – Requires improvement.

Are services responsive? – Inadequate.

Are services well-led? – Inadequate.

At this inspection we found:

  • Improvements to the systems, processes and practices that helped to keep patients safe and safeguarded from abuse were insufficient.
  • The practice had not made sufficient improvements to the assessment and management of risks to patients, staff and visitors.
  • Information to deliver safe care and treatment to patients was not always available to staff.
  • Improvements to the arrangements for managing medicines to help keep patients safe were insufficient.
  • Staff did not report significant events they had been made aware of through feedback left on the NHS Choices website.
  • The practice was still not keeping records of action taken (or if no action was required) in response to receipt of all notifiable safety incidents.
  • Not all staff were up to date with essential training.
  • Feedback from patients was not always positive about the way staff treated them.
  • Results from the national GP patient survey showed that the practice was consistently below local and national averages for its satisfaction scores on the helpfulness of reception staff.
  • A practice website had been created.
  • Patients were not always able to access care and treatment from the practice within an acceptable timescale for their needs.
  • The practice was unable to demonstrate they had an effective system to manage complaints and concerns.
  • Improvements to governance arrangements at the practice had taken place but were insufficient.
  • Improvements to processes for managing performance were insufficient.
  • The practice had not formed a patient participation group.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

Following two consecutive periods of special measures, insufficient improvements have been made such that there remains a rating of inadequate for providing safe, effective, responsive and well-led services as well as for all patient population groups. We will now move to close the service by cancelling the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice