Archived: Goldington Road - Dr Das Also known as Dr Das' Surgery

We carried out an announced comprehensive inspection at Goldington Road – Dr Das on 7 December 2023.

Overall, the practice is rated Inadequate.

The ratings for each key question are:

Safe - Inadequate

Effective - Inadequate

Caring – Requires Improvement

Responsive – Requires Improvement

Well-led – Inadequate.

Following our previous inspection on 8 March 2017, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Goldington Road – Dr Das on our website at www.cqc.org.uk.

Why we carried out this inspection

We inspected Goldington Road – Dr Das as part of our regulatory functions under the Health and Social Care Act 2008.

We carried out this inspection in response to concerns and risk we identified through our ongoing monitoring of the service.

We looked at all the key questions (safe, effective, caring, responsive and well-led) for this inspection. We also followed-up the areas identified at our last inspection where the provider should make improvements.

How we carried out the inspection

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 facilities
• completing clinical searches and reviewing patient records on the practice’s patient records system to identify issues and clarify actions taken by the provider
• requesting evidence from the provider
• a site visit to Goldington Road – Dr Das
• requesting and reviewing feedback from staff and patients who work at or use the service.

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
• information from the provider, patients, the public and other organisations.

We found that:

People were at high risk of avoidable harm. For example, the practice:

• had not completed all appropriate recruitment checks and Disclosure and Barring Service (DBS) checks for all staff, and staff had not all received immunisations or measures put in place to reduce risks to staff and patients associated with infectious diseases

• staff had not all completed training in fire safety, infection prevention and control (IPC) and sepsis awareness, nor completed training in safeguarding children and adults in line with national guidance

• had not completed health and safety risk assessments effectively, or identified and acted on recommendations in them to reduce and manage risks, such as around IPC

• did not record, control, monitor and store blank prescriptions in ways that minimised their unauthorised access or use

• staff sometimes administered medicines to patients without proper authorisation in place

• did not always monitor and review patients in line with national guidance, for example to make sure medicines were prescribed for patients only when it was safe to do so, or respond fully to protect patients affected by safety alerts

• did not keep all recommended medicines and equipment for use in an emergency; regularly check they were always safe, adequate, working and available if they were needed; and not all staff knew where emergency medicines and equipment were kept

• missed opportunities to prevent or minimise harm, for example they did not identify and share learning to make improvements in response to incidents, near misses or significant events

Patients were not always offered effective care and treatment. For example:

• Patients’ immediate and ongoing needs were not always fully assessed, patients with symptoms of a possible serious illness were not always followed up in a timely and appropriate way, and the practice did not monitor all patients with long-term conditions in line with national guidance.

• The practice was unable to demonstrate staff had the skills and knowledge to carry out their roles and that they did so competently and safely. Staff worked outside their scope of practice.

• Staff were not always supported to do training and did not have access to inductions, professional support, supervision and appraisals.

• Non-clinical staff regularly worked in the practice when no clinical staff were available to support them or a patient if needed, including to carry out clinical tasks and outside of the practice’s opening times.

• Concerns around staff performance were not managed effectively.

• Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions were not made in line with legislation. Patients were not always supported to make decisions, and when decisions were made on a patient’s behalf, these were not made in line with legislation.

There were times when people did not feel well-supported, involved in their care, or treated with compassion, kindness, dignity and respect. However:

• some staff helped patients find further information and access support services to help them manage and improve their own health

• although there was limited information in waiting areas in the practice about support groups and organisations, information was available on the practice’s website, particularly about support for recently bereaved people

• some staff could offer to speak with patients in some languages other than English. However, there were no arrangements for accessing appropriate interpreters for other patients.

The practice environment did not always ensure patient’s dignity and confidentiality was maintained, and the facilities and premises were not always suitable for the services being delivered.

However, the practice organised and delivered services to meet patients’ needs, and people could usually access appointments at the practice in a timely way.

Complaints were not listened and responded to or used to improve the quality of care and service.

The leadership, management and governance of the practice did not support the delivery of high quality care, or an open and fair culture that supported learning and innovation. For example:

• Leaders did not show they understood the challenges to quality and sustainability, had identified actions to address those challenges, or had a clear vision and strategy that included planning for the future of the practice.

• Staff reported leaders were not always visible and approachable, did not value them, did not give enough attention to their safety and well-being, bullied them, and described a tense and unprofessional working atmosphere.

• Not all staff felt they could raise concerns without fear and some staff felt concerns or views they shared with leaders were not welcomed or acted on.

• There was a lack of trust between some staff, and staff felt leaders did not always take responsibility when they thought they should, were not honest and transparent about the practice’s performance, and dismissed concerns they or people using the service raised.

• The practice did not involve the public, staff and external partners effectively to deliver high quality and sustainable care.

• The practice did not have effective governance arrangements nor clear and effective processes for managing risks, issues and performance.

• The practice did not always manage and store patient information, for example medical records, safely and securely.

We found one breach of regulation. The provider must:

• Establish effective systems and processes and operate them effectively to ensure good governance and compliance with the requirements of the fundamental standards of care as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also identified the following areas for improvement where the provider should:

• Work towards fully embedding clear processes for all staff to identify and report safeguarding concerns.

• Seek and respond to feedback from the public, patients, staff, external partners, and findings from surveys such as the national GP Patient Survey to improve the service.

• Consider introducing a programme of quality improvement activity to routinely review the effectiveness and appropriateness and monitor the outcomes of care and treatment.

• Continue to monitor and take actions to improve attendance for cervical screening.

• Expand ways to help patients find further information and access support services, such as providing information in patient waiting areas in the practice.

• Monitor and take actions to improve patient access, particularly around making staff and patients aware of arrangements for accessing interpreters, making adaptations to the building to support patients with a wide variety of needs, and improving access to home visits from suitable professionals.

• Develop a clear vision and strategy for the practice and plan for the future of the practice.

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

We have taken action, in line with our enforcement powers, to ensure people using this service are kept safe. The provider is no longer providing regulated activities and services.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care