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

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