Archived: Mr Shambhu Nath Keshri Also known as Chelmsford Medical Centre.

Updated 12 May 2016

Chelmsford Medical Centre is situated in Grimsby in an urban area. It is within a row of buildings which are primarily shops. There is no car park but there are parking facilities to the front of the practice. The practice has a GMS contract with NHS England (North Yorkshire and Humber Area Team) and is part of NHS North East Lincolnshire CCG. The practice has an Index of Multiple Deprivation (IMD) decile of 1. The lower the IMD decile the more deprived an area is. People living in more deprived areas tend to have greater need for health services The practice has a list size of 140 patients.

The practice is a single handed GP practice with one other member of staff. The GP is male and the member of staff is female. The member of staff is responsible for reception duties, cleaning, chaperoning and acts as Practice Manager. The practice is not a teaching or training practice.

The inspection was unannounced following concerns raised with the Care Quality Commission from NHS England following a visit by them on 9 January 2016. The concerns related to access to the practice, the environment, infection prevention and control and information governance. The practice had not been previously inspected by the Care Quality Commission.

The practice is open from 10.15am to 11.30am Monday to Friday, 3.30pm to 4.30pm Monday, Thursday and Friday and 3.30pm to 6.30pm on Tuesday. No practice website and online facilities are available. The practice telephone number has an answerphone message with the GP’s mobile number for assistance when the practice is closed in core hours. Out of hours care is provided by NHS North East Lincolnshire CCG.

Updated 12 May 2016

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at Mr Shambhu Nath Keshri, 128 Chelmsford Avenue, Grimsby, South Humberside, DN34 5DA on 3 March 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 resources, systems and processes were not in place to keep them safe. For example, the management of patients medicines, the call and recall of patients, the system for reviewing hospital discharge and clinic letters, supervision and support of staff and the management of safeguarding.

• Staff were not clear about reporting incidents, near misses and concerns as there was no evidence of learning and communication with staff. When there were unintended or unexpected safety incidents, reviews and investigations either did not take place or were not thorough enough to support improvement. Action was not taken to mitigate future risk and so safety was not improved.

• There were no investigation records available for either significant events or complaints and no records to show patients had received a written apology.

• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.

• Data, records and feedback from staff showed that care and treatment was not delivered in line with recognised professional standards and guidelines. For example the GP was unaware of recognised standards and guidelines (such as Gillick competence) and was unable to give an example of when they last used National Institute for Health and Care Excellence (NICE) Guidance.

• Reviews of patient records identified serious concerns with the way patients were managed.

• Patients were frequently unable to access the care they needed. Services were not set up to support patients with complex needs or patients in vulnerable circumstances.

• The service had little or no clinical governance systems (clinical governance is a system through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish). There was evidence that known risks had not been acted on.

• There was no system in place to monitor outcomes of intervention including holding clinicians to account for their clinical decisions. There was no system in place to support peer review and enable shared learning.

• The practice was a single handed GP practice with one member of staff. There was no clinical leadership at the practice and staff were not supervised nor had their competency assessed. There was no evidence of any recent mandatory staff training.

The Provider Must:

• Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

• Take action to address identified concerns with infection prevention and control.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

• Carry out clinical audits including re-audits to ensure improvements have been achieved.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements

• Improve processes for making appointments.

In relation to all of the areas of concern identified during the inspection, NHS England were informed of the risks identified during our inspection.

Following our inspection, due to the serious concerns identified we gave the provider, Mr Shambhu Nath Keshri, notice that we were cancelling his registration with the Care Quality Commission (CQC) under section 31 of the Health and Social Care Act 2008.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 12 May 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

• None of these patients had a personalised care plan.

• There were no registers of patients with long-term conditions.

• Structured annual reviews were not undertaken to check that patients’ health and care needs were being met.

• Medication reviews were not being undertaken.

Updated 12 May 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

• There were no systems to identify and follow up patients in this group who were living in disadvantaged circumstances and who were at risk.

• Data showed that 0% of children had received the MMR vaccine at 12 months compared to the CCG average of 97.3%.

Updated 12 May 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

• The safety of care for older patients was not a priority and there were limited attempts at measuring safe practice.

• We saw evidence which showed that basic care and treatment requirements were not met. For example; the practice did not have any equipment other than a blood pressure monitor.

• The care of older people was not managed in a holistic way.

The leadership at the practice had little understanding of the needs of older people and they were not attempting to improve the service for them. Services for these patients were therefore reactive. There was no attempt to engage with this patient group in order to improve the service.

Updated 12 May 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

• Appointments could be booked by telephone and face to face.

• There were no early or extended opening hours for working people.

• There was no evidence of health checks and health screening taking place.

• No online facilities were available.

Updated 12 May 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

• The practice was unable to identify patients

• They had not worked with multi-disciplinary teams in the case management of people experiencing poor mental health.

• They did not carry out advance care planning for patients with dementia.

• The practice had not told patients experiencing poor mental health about support groups or voluntary organisations.

• The practice did not have a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health.

• Staff had not received training on how to care for people with mental health needs or dementia.

Updated 12 May 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

• The practice did not hold a register of patients living in vulnerable circumstances. They were unable to identify the percentage of patients who had received an annual health check. The practice had not worked with multi-disciplinary teams in the case management of vulnerable people.

• Staff did not know how to recognise signs of abuse in vulnerable adults and children and they were not aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies out of normal working hours.