Dr AM Deshpande & Dr P Gurjar Practice Also known as Dr A Deshpande & Partners

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same. We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

Leaders were aware of the challenges of delivering safe, sustainable high-quality care. Whilst there was no firm plan in place, the practice had continued to work closely with the PCN on matters relating to oversight, governance, staffing, systems and processes.

Practice leaders recognised the need to be visible and support staff, and the majority of staff felt supported, able to give feedback and said they were treated equally. However, due to working patterns, practice leaders were not always on site for advice and guidance.

Leaders had a good understanding of local population issues and the challenges and priorities for their service, including making physical improvements to the surgery.

There was evidence of systems and processes for learning and continuous improvement. However, the system for the oversight of the completion of staff training was not effective and the system for the oversight of professional registration checks needed to be strengthened.

Most governance processes which supported the safe delivery of care and used information to monitor and improve performance, were effective.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a clear vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Although staff had not formally contributed to the development of the practice vision and strategy, staff had opportunities to contribute to future plans by raising ideas and suggestions at practice meetings and via conversations with the practice leaders.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Although not all leaders were physically present on-site during surgery hours, they had the skills, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the local area and were engaged in the development of primary care services within the primary care network.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

Staff were aware of how to raise concerns and felt leaders would listen to them. The practice had established Freedom to Speak up arrangements with other practices in the primary care network.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. We saw that leaders had addressed needs and made individual adjustments to ensure all staff were valued, for example changes in working patterns, and addressing specific training method preferences.

The service had clear responsibilities and roles and systems of accountability. They acted on the best information about risk, and outcomes, and shared this where appropriate. The service, working as part of the PCN, had effective governance and management systems where information and data were used appropriately to monitor risk, performance and quality of care.However, the system for the oversight of the completion of training was not effective. Although leaders told us that all staff had completed the necessary training, there was no oversight of this available during the inspection. This was partly due to the streamlining of processes which was in progress during the assessment. Immediately following the inspection, leaders sent us evidence that most of the required training had been completed. However, there were some remaining gaps, which leaders told us would be actioned without delay.

Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network, for example, to offer extended access, and flu and covid vaccination programmes. The practice worked also closely with the primary care network and local practices to provide mutual support in terms of staffing, information sharing and best practice.

At the time of the assessment, there was no patient participation group in place, but we saw that staff had been working on this for a period of time. To address this, staff from the practice and the PCN, had begun to develop plans to establish a joint PPG for the local area.

The practice did, however, gather patient feedback from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. Overall, feedback from patients was positive.

Staff and leaders told us that learning needs were identified through annual appraisals, and team feedback. Staff understood their duty to raise concerns, report incidents and near misses. Staff told us that they had received enough specific training for their role.

The provider had well-established systems for monitoring significant events and complaints. Whilst there was evidence of analysis of incidents and complaints, there was no recorded evidence that the actions identified had been implemented and therefore no evidence that they were adequate to mitigate future risk.

The practice had a limited programme of clinical audit to monitor and drive improvement. However, they did participate in some local quality improvement initiatives, including the Medicines Optimisation Local Enhanced Service, (MOLES), designed to improve the safe, effective, and cost-effective use of medicines. We saw unverified data that the practice had achieved positive results as a result of being part of this programme, including providing local net prescribing savings and measurable improvements in medicines safety.