The Care Quality Commission
  • Doctor
  • GP practice

Dr R Khanchandani's Practice

Overall: Requires improvement read more about inspection ratings

The Blenheim Medical Centre, 9 Blenheim Crescent, Luton, Bedfordshire, LU3 1HA (01582) 404012

Provided and run by:
Dr R Khanchandani's Practice

All Inspections

5 August 2021

During a routine inspection

We carried out an announced inspection at Dr R Khanchandani's Practice on 5 August 2021. Overall, the practice is rated as Requires Improvement.

The ratings for each key question are:

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive - Requires Improvement

Well-led - Good

We carried out an announced comprehensive inspection at Dr R Khanchandani's Practice on 12 March 2020. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our regulatory functions. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. We carried out an announced follow up inspection on 25 November 2020 to see if improvements had been made. The overall rating at the November 2020 inspection was requires improvement with inadequate for providing responsive services. Therefore, the service remained in special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr R Khanchandani's Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • The five key questions: are services safe, effective, caring, responsive and well-led?.
  • Any breaches of regulations or areas we identified at the previous inspection, where the provider should make improvements.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall and for all population groups.

We rated the practice as good for providing safe services because:

  • Improvements had been made to other systems, practices and processes in place to keep people safe.
  • Staff vaccination records did not show documentary evidence that vaccines had been received and Patient Group Directions were not all current and appropriately authorised for staff to administer the medicines. However, immediately following the inspection, the practice provided evidence that appropriate actions had been taken to rectify the issues.

We rated the practice as requires improvement for providing effective services because:

  • The practice had implemented measures to increase the uptake of cervical screening and childhood immunisations. There had been no new data published since the previous inspection to demonstrate the improvements made.
  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect.
  • Feedback from patients was positive regarding the care they received.
  • The practice had measures in place to support carers and increased the number of patients identified as having caring responsibilities.

We rated the practice as requires improvement for providing responsive services because:

  • Actions had been taken to improve patient satisfaction with the way they were able to access care and treatment in a timely way. There had been an improvement to some results of the National GP Patient Survey. However, the results remained lower than local and national averages.
  • The practice identified learning from complaints and documented actions to prevent reoccurrence.

We rated the practice as good for providing well-led services because:

  • Governance structures had improved, and the practice had developed a practice improvement plan to continue to make positive changes.
  • Policies and procedures put in place were embedded in the practice.
  • Staff were supported and were positive regarding the GP partners and practice management.

Whilst we found no breaches of regulations, the provider should:

  • Obtain documentary evidence that staff have received appropriate vaccinations in line with current Public Health England (PHE) guidance if relevant to role.
  • Have a system in place to manage Patient Group Directions (PGDs) so the information available is current and staff are authorised to administer vaccinations.
  • Continue to take action to increase the uptake of cervical screening and childhood immunisations.
  • Embed the changes made to improve patient satisfaction particularly in relation to access and appointment booking.

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

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

25 November 2020

During a routine inspection

We carried out an announced comprehensive inspection at Dr R Khanchandani's Practice on 12 March 2020. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our regulatory functions. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. The full comprehensive reports of the March 2020 inspection can be found by selecting the ‘all reports’ link for Dr R Khanchandani's Practice on our website at www.cqc.org.uk

This announced comprehensive inspection on 23 to 25 November 2020 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews remotely on 23 to 24 November 2020 and carried out a site visit on 25 November.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and inadequate for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • Some of the systems, practices and processes put in place to keep people safe had not been fully implemented and followed.
  • Improvements had been made to ensure appropriate standards of cleanliness and hygiene were met and systems were in place to assess, monitor and manage risks to patient safety.
  • A system had been put in place to learn and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

  • The uptake for cervical screening and baby immunisations was below the national targets. Actions taken to make improvements had not yielded the necessary improvements so far.
  • Some improvements since the March 2020 inspection had been made. For example.
    • Care plans were in place as necessary for patients, so care was delivered and reviewed in a coordinated way.
    • Staff had access to online training. Records of completed training were kept and staff had completed essential training.
    • A process was in place to ensure clinical overview for non-medical prescribers.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect.
  • Feedback from patients was positive regarding the care they received.
  • The practice had measures in place to support carers. However, less than 1% of the practice population was identified as having caring responsibilities.

We rated the practice as inadequate for providing responsive services because:

  • The results of the National GP Patient Survey highlighted that patients were not always able to access care and treatment in a timely way. Actions had not been taken to address the lower than average patient satisfaction.
  • Learning from complaints and actions taken to prevent re-occurrence were not documented.
  • Complaint responses did not always contain information for the complainant to contact the Parliamentary and Health Service Ombudsman if they were not satisfied with the outcome of the complaint or how it was dealt with.

We rated the practice as requires improvement for providing well-led services because:

  • There were still some concerns related to good governance within the practice.
  • The systems, practices and processes put in place had not been established fully and operated effectively to ensure compliance with requirements to demonstrate good governance.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to identify and support patients with caring responsibilities.
  • Continue to improve and monitor patient satisfaction.
  • Continue to take actions to increase the uptake of cervical screening and childhood immunisations.
  • Include the details of the Parliamentary and Health Service Ombudsman in complaint responses to patients.

This service was placed in special measures in May 2020. Insufficient improvements have been made such that they have been rated inadequate for providing responsive services. Therefore, the service will remain 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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

12 March 2020

During an inspection looking at part of the service

We carried out an announced focussed inspection at Dr R Khanchandani's Practice on 12 March 2020 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions

  • Safe
  • Effective
  • Well led

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall and requires improvement for all population groups.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems, practices and processes to keep people safe
  • Appropriate standards of cleanliness and hygiene were not met.
  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • The practice did not have systems for the appropriate and safe use of medicines.
  • The practice did not have a system to learn and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

  • Care was not delivered and reviewed in a coordinated way. There were no formal care plans in place for patients.
  • The uptake for cervical screening and baby immunisations was below the national targets.
  • There was no overview of training completed. Some essential training had not been completed.
  • There was no formal clinical overview for non-medical prescribers.

We rated the practice as inadequate for providing well-led services because:

  • There were concerns related to good governance within the practice.
  • The practice did not always have clear and effective processes for managing risks, issues and performance.
  • There was little evidence of systems and processes for learning, continuous improvement and innovation.
  • The areas where the provider must make improvements 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.

The areas where the provider should make improvements are:

  • Improve the uptake for cervical screening, cancer screening and baby immunisations.

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.

We are mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service as required to keep people safe and to hold the provider to account where it is necessary for us to do so.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

12 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr R Khanchandani's Practice on 12 November 2014.

The practice achieved an overall rating of Good. This was based on our rating of all of the five domains. Each of the six population groups we looked at achieved the same good rating.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

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

Importantly the provider should:

  • Ensure staff are up-to-date in role specific safeguarding training
  • Introduce suitable measures to audit the effectiveness of the infection control policy
  • Ensure the cloth covered chairs in the waiting room at the Link Surgery are replaced as per the practice’s recently agreed replacement programme
  • Ensure all staff are familiar with fire evacuation procedures
  • Make available written information for carers to ensure they understood the various avenues of support available to them
  • Check that the learning points implemented from the analysis of significant events has had the desired effect and changed clinical care and practice
  • Monitor the newly introduced documented system at the Link Surgery so medicines are stored securely and kept at the required temperatures

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

29 January 2014

During a routine inspection

During our inspection, we found the service to be welcoming with friendly staff. We spoke with the majority of the staff available during our visit and nine people attending the practice as patients.

We found information was clearly displayed throughout the surgery for people using the service, including health promotion leaflets and information about the practice including the services available. In addition people were advised about how to raise any concerns if they were not happy with the service provided.

A touch screen facility enabled people to announce their arrival and the reception area was fully staffed. All of the surgeries and treatment rooms were on the ground floor and the practice was fully accessible to all.

People told us they had confidence in the staff working out of the practice. Most people were happy with the appointment system, although three people told us they would prefer the opportunity to book appointments on the day rather than have a system whereby they could arrive and wait to be seen.

Thee provider had systems in place to regularly assess and monitor the quality of service that people receive. Some of these systems involved contacting the people who use the service to ascertain their opinions.

We reviewed the quality monitoring systems used within the service and saw these to be effective, with evidence of learning from areas identified through feedback from patients, audits and monitoring.