Dr Raju and Partners

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Electrical, gas and calibration checks had been appropriately completed and risk assessments were in place, for example, for the storage of oxygen.

The service had maintenance contracts in place however, contractors did not consistently provide the required documentation to assure leaders that all safety standards were being met. To address this, leaders had met with the contractors to clarify expectations and a designated staff member carried out weekly premises audits to identify and report hazards. For example, a torn carpet in the waiting room. To prevent legionella, systems were in place for regular tap flushing. The provider had tried to gain assurance from the contractor for the building that the necessary water temperature checks were being consistently carried out however, this had not been provided.

Fire safety drills had been completed and a designated fire marshal was in place to manage emergencies. The premises were secure, with restricted access to staff offices and signs informing people that CCTV was in operation. For additional safety and premises monitoring, security guards were stationed within the building. We found shortfalls regarding public information. There were no instructions or notices in the waiting room to advise people using the service of evacuation procedures or designated fire assembly points.

The practice did not have effective systems in place to monitor and track prescription stationery, and access to the key for the locked prescription storage cupboard was unrestricted. This compromised the security of blank prescriptions. Following our onsite assessment, the provider submitted an updated policy that addressed these safety concerns.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.
 

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, an advanced nurse practitioner and an advanced clinical practitioner. Leaders had ensured that most staff were up to date with the training the service had deemed mandatory and that staff operated within their agreed areas of competence.

The service did not always follow safe recruitment procedures when employing staff, which were in line with national legislation. Following our on site assessment, the provider sent us their updated recruitment policy which reflected legal requirements. Systems were not in place to provide reassurance that staff employed by the Primary Care Network (PCN), and working in the practice, had been appropriately recruited, trained and supported. Following our on site assessment, the practice sent to us a Memorandum of Understanding between the PCN and the practice to confirm this was in place. Clinical supervision was in place for non-medical prescribers however, this was not documented. The provider informed us they would document when clinical supervision had been completed.
 

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Spill kits for bodily fluid spillages were in place but staff required training on their use.

The premises appeared clean and tidy and appropriate processes for the disposal of clinical waste were in place. We reviewed a sample of equipment and medical consumables which were found to be visibly clean and in date.

The service’s infection prevention and control (IPC) lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. An action plan was in place to mitigate any risks identified. We found that the IPC risk assessment had not identified carpets in the waiting room and non-wipeable chairs in clinical rooms as potential risks. There was a record of staff immunisations against potential health care acquired infections for staff employed by the practice. However, this information was not available for locum staff.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. For example, weekly spot checks and a logbook to request issues identified were addressed by the contractor. Most staff had completed relevant training in IPC.
 

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.