Dr I K Babar & 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 that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed.

The service was in breach of legal regulations in relation to safe care and treatment, good governance, staffing and fit and proper persons employed.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was no monitoring of significant events (SEAs) as they had not been collated to show what had been received and when any action was completed, until our assessment was announced. Where patient information had been sent to an incorrect organisation, a data breach had not been considered. SEAs were not discussed in meetings. The provider told us they were discussed once a year in July, but they were unable to provide evidence when asked.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients.

The service did not always work with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. We were told that each GP had their own inbox to monitor test and lab results. Any urgent results would be handled by the duty doctor.

We found boxes of people’s health records being stored in a room that was not locked. The room was easily accessible to anyone because it was located directly off a public area.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Training was not monitored throughout the practice. We asked for evidence staff had been trained in safeguarding adults and children, but this was not available for most staff, including clinicians. Evidence of training by the lead GPs for safeguarding could not be provided. A Safeguarding policy was in place and staff were aware of who the safeguarding lead was.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enable people to do the things that mattered to them.

The service encouraged patients to attend for health screening; however, the most recently published data showed us that uptake for cervical screening was significantly below the local and national average.

Patients who were prescribed high risk medicines were not always called for regular checks in line with national guidance.

Not all emergency equipment was available, and checks were not in place to ensure the equipment was in working order. Not all staff could recognise a deteriorating patient and did not know what action to take. There was no evidence that staff had completed basic life support or Sepsis training.

Patients were not always advised on risks related to their condition and what actions to take if their condition deteriorated.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The practice had 2 fire wardens who both worked part time. No evidence of fire warden training was held for either of them. Evidence of fire safety or health and safety training was available for less than 50% of staff.

The practice was located in an NHS Property Services managed building and NHS Property Services were responsible for most checks. However, the practice had not completed any of their own risk assessments to provide assurance that the part of the building they occupied was safe and fit for purpose. Due to the layout of the waiting area and the practice displaying posters on the window staff were unable to monitor patients and respond should a patient deteriorate.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Safe recruitment procedures were not followed. Evidence of identity was not routinely held, and we saw little evidence of the practice carrying out Right to Work checks or having a full employment history for their staff. They did not check that GPs and nurses were registered with the appropriate regulatory body.

The practice did not routinely carry out disclosure and barring checks for staff, and where they had they were unable to provide evidence that these were accurate or that they had been carried out prior to employment starting. They did not risk assess staff roles as to which role required a DBS check.

The practice did not monitor staff training, and they told us they had not checked what training some staff, including clinicians, had completed. We saw no evidence of mandatory training, such as in safeguarding, infection prevention and control, fire safety and Basic Life Support for over 50% of staff.

Most staff, including clinicians and managers, had not had an appraisal since before 2020. Some staff who had worked at the practice for over 10 years had never had an appraisal.

Staffing rotas for administrative staff were available and showed us they had enough staff available to meet the demands of the service. We requested evidence of staffing levels for other roles within the service, but this was not provided when we requested it during and following the assessment.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead but there was no evidence available to prove they were qualified to fulfil this role. There was no evidence of any infection prevention and control training for many of the staff which included managers employed by the provider.

An infection prevention and control risk assessment had been completed the week prior to our visit, but it was not accurate. Several aspects had been recorded as being compliant, when we found evidence, they were not. For example, privacy curtains in the clinical rooms had not been changed since July 2023. There was no process to monitor the standard of cleaning or infection prevention and control throughout the practice.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning.

Training was not monitored by the practice. Evidence was not held of staff being trained and their competency being assessed on medicines optimisation.

The practice did not hold all the recommended emergency medicines. They had not completed any risk assessments to determine if they were required.

As part of the assessment we conducted a series of remote clinical searches of patient records. Patients taking high risk medications that required regular monitoring were not always called or recalled where required in line with guidance. The process in place for call/recall/identifying these patients was not robust.

We also reviewed the prescribing and monitoring of a medicine that can be harmful if not taken correctly, so regular monitoring and clear instructions are essential. We found examples where the day of the week the medicine should be taken had not been recorded, and shared care agreements were missing. This increased the risk of unsafe prescribing and administration.

The practice did not manage prescription stationery securely, nor in line with national NHS guidance. There was no prescription security policy and serial numbers of any prescriptions held at the practice were not recorded. Paper prescriptions were not tracked safely within the practice, which could increase the risk of misuse or prescription fraud. This indicated a lack of effective systems to protect against potential prescription fraud. For example, prescriptions were kept in unlocked printers within unlocked rooms and were not secure. We found a completed prescription containing patient information in an unlocked room. This was dated the day prior to our site visit. The Registered Manager removed this from the printer but did not lock the room which held the prescriptions in the printer.