• Doctor
  • GP practice

Archived: Dr Saptarshi Saha Also known as Dr S Saha Surgery

Overall: Good read more about inspection ratings

Darlaston Health Centre, Pinfold Street, Darlaston, Wednesbury, West Midlands, WS10 8SY (0121) 568 4210

Provided and run by:
Dr Saptarshi Saha

All Inspections

11 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Saptarshi Saha also known as Darlaston Health Centre on 25 May 2016. The overall rating for the practice was inadequate and the practice was placed in to special measures for a period of six months. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Saptarshi Saha on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 11 April 2017. Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice operated effective systems for reporting and recording significant events. Significant event logs showed that the practice had responded and learned from safety incidents.
  • Effective system were in place to receive and act on alerts from the Medical and Healthcare products Regulatory Agency (MHRA) alerts.

  • At our May 2016 inspection, some medicines required to respond to medical emergencies were not stored within the practice. During this inspection we found that the arrangements to respond to medical emergencies had been strengthened.
  • The practice had clearly defined and embedded systems to minimise risks associated with legionella, fire and health & safety.
  • Overall Quality Outcomes Framework (QOF) performance remained above local and national averages. Uptake of bowl cancer screening had increased since the May 2016 inspection.

  • Clinical guidelines were cascaded to all the clinical team; staff had the skills and knowledge to deliver effective care and treatment. The practice used clinical audits in most areas to monitor quality improvements. However, audits of completed joint injections were not being carried out.

  • The July 2016 national GP patient survey showed areas where patient satisfaction had either increased or declined since the previous inspection. The practice were aware of these results and took actions to improve patient satisfaction.
  • Completed Care Quality Commission comment cards showed that patients felt they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Previously complaints were not being managed effectively. During this inspection the practice were able to clearly demonstrate improvements made to the quality of care as a result of complaints and concerns. New ways of working were established in response to survey results.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Staff felt supported by management. The practice had a number of policies and procedures to govern activity which staff had access to and held regular practice meetings. However, there were areas where oversight of some procedures were not carried out effectively such as managing uncollected prescriptions.
  • The practice sought feedback from staff. The practice had an active patient participation group (PPG) and we saw measures in place in order to increase PPG membership and seek feedback from patients, which it acted on.

However, there were areas of practice where the provider should make improvements.

  • Ensure staff are aware of practice policies and procedures and that these are adhered to and operated effectively.

  • Establish an effective system for monitoring the overall stock of prescription stationery.

  • Ensure clinical improvement initiatives are monitored to measure performance and quality improvements in all areas of need.

  • Continue to consider ways of encouraging the uptake of national screening programmes such as bowel and breast cancer.

  • Continue to review national GP patient survey results, internal patient feedback and explore effective ways to further improve patient satisfaction. Explore options to enable patients to be treated by a clinician of the same sex if and when requested.

  • The practice should explore initiatives to improve engagement with patient groups where exception reporting is above local and national averages.

  • Explore how to provide a service for patients who are unable to attend the practice.

  • Ensure clinical performance initiatives are carried out to monitor quality improvements.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Saptarshi Saha on 25th May 2016 Overall the practice is rated as inadequate.

We inspected Dr Saha’s practice in October 2014. During the inspection we found there were breaches in three regulations. Regulation 17, Good Governance, Regulation 18, Staffing and Regulation 19, Fit and Proper Persons Employed. We rated the practice as requires improvement. Following the inspection the provider sent us an action plan detailing the action taken to ensure compliance with the regulations. We reviewed the action plan as part of the inspection on 25 May 2016.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, documentation did not always demonstrate a thorough investigation and where the practice had closed the learning loop. Patients did not always receive an apology.
  • Risks to patients were not always assessed and well managed, for example the practice could not demonstrate an effective system for recording actions following receipt of medicines and healthcare products regulatory (MHRA) alerts.
  • Although some audits had been carried out, there was little evidence that audit was used to drive quality improvements to patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they felt involved in their care and decisions about their treatment.
  • Patients said they found it easy to make appointments with the GP when they needed one, with urgent appointments available the same day. Requests for home visits were triaged by a GP and mainly passed over to the rapid response team or patients were seen within the practice.
  • The practice had an established system to ensure staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • The system to ensure staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment was not thorough enough.
  • They had a number of recently updated policies and procedures to govern activity; however they were not fully imbedded.

The areas where the provider must make improvement are:

  • Carry out full cycle clinical audits to improve patient outcomes.
  • The practice must ensure that internal procedures for responding to nationally recognised guidance for delivering safe care and treatment; including patient safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) are followed through to full completion.
  • Ensure appropriate risk assessments are in place in the absences of medication not available to respond to medical emergencies.
  • Ensure staff receive appropriate training to enable them to carry out their duties effectively.
  • Ensure that equipment is suitable for its purpose, properly maintained and used correctly and safely. For example, the practice must ensure that back up systems used to monitor vaccination fridge temperatures are working appropriately.

The areas where the provider should improvement are:

  • In the absence of a Patient Participation Group the practice should consider how they collate, discuss and support actions needed to respond to feedback following receipt of views from people who use their service.
  • Satisfy themselves that regular checks to the building are carried out and risk assessments relating to the health, safety and welfare of people using the services are completed; with action plans for managing identified risks. For example ensure appropriate fire safety checks are carried out.
  • Review the system in place for monitoring the cleaning of the environment to ensure good infection prevent and control.
  • Explore how that practice can further identify and support patients who act as carers.
  • The practice should send acknowledgement letters to complainants as detailed in their complaints policy. A record of complaints should not be maintained in patient records.
  • Report all safety incidents and thoroughly record actions taken ensuring lessons learnt are fully communicated.

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

3 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We completed a comprehensive inspection at Darlaston Health Centre on 3 October 2014. The overall rating for the practice is that it requires improvement. We found the practice to be good in the caring and responsive domains and requires improvement in the safe, effective and well-led domains. We found the practice required improvement in the care provided to people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health.

Our key findings were as follows:

  • Staff were aware of their responsibility to report and record significant events; however there was limited evidence to demonstrate learning and dissemination of information to staff or others who were involved in the significant event. Lessons learnt were not always recorded to ensure that all staff had been made aware of any learning or actions required.
  • NHS health checks had only been completed for 9% of the practice population aged 40 – 74 up until December 2013. These health checks are a method used to identify those patients at risk of developing long term conditions.
  • Staff were caring and treated patients with dignity and respect.
  • Robust systems were in place for handling concerns and complaints. Changes in practice had been made due to lessons learned.
  • Staff worked well as a team and good management support systems were in place.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Implement robust recruitment processes to ensure only suitable staff are employed and recruitment processes reflect the requirements set out in Schedule 3 of the Health and Social Care Act 2008.
  • Ensure that staff have appropriate training and support in relation to their duties and roles. Identify and deliver training and awareness to staff to enable them to deliver care safely and to an appropriate standard and provide up to date records to demonstrate that staff have undertaken appropriate training.
  • Implement effective systems for identifying, assessing and management of risks to patients and others for example risk assessment and safe systems for dealing with emergencies, staffing and recruitment.

In addition the provider should:

  • Review the staff group knowledge and understanding regarding the chaperone process to ensure it reflects the published General Medical Council (GMC) guidance for ‘Intimate examinations and chaperones.
  • Develop the Incident/significant event reporting, recording and monitoring process to ensure trends and lessons learnt are captured and shared internally, and where appropriate externally.
  • Develop systems to demonstrate that medication to be used in an emergency is available and within its expiry date.
  • Provide risk assessments and maintenance records which demonstrate that the premises and equipment do not provide a risk to staff or patients.
  • Ensure information on how to make a complaint is freely available to patients.
  • Make patients aware that a hearing loop system is available at the practice.
  • Ensure that the practice’s disaster recovery plan provides staff with sufficient information regarding the action to take if there was a loss of services or facilities at the practice.
  • Develop systems to obtain patient feedback, for example a patient participation group.
  • Ensure patients have access to information about health promotion and support services available.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice