Dr BK Jaiswal's Practice

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

We looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating has lowered to requires improvement. Although the provider submitted additional evidence after the assessment, some of this should have been in place at the time of our inspection. As a result, we found that leaders and managers did not have sufficient oversight of systems and processes to ensure the safe delivery of services at the time of the assessment.

This service scored 62 (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 had a mission statement which included providing safe, effective, compassionate, and person-centred care to all patients, with a commitment to treating every individual with dignity, respect, and kindness while promoting health, wellbeing, and independence. The provider explained this was discussed with staff. Many staff had worked at the practice for a long period of time because they liked the culture.

The provider and practice manager monitored and reviewed progress against the delivery of their strategy. Business continuity and disaster recovery plans were in place to ensure resilience in adverse circumstances. The provider was in the process of reviewing opportunities to ensure the succession of the practice.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The assessment demonstrated improvements were required in some of the practice governance systems and processes to ensure a safe service. This was because leaders and managers generally did not have effective oversight of systems and processes to promote safe service provision. For example:

• A review of the staff recruitment records demonstrated gaps in staff records. Following the assessment the leaders carried out a full audit of recruitment records to identify and rectify any gaps.
• The practice did not have a record of staff immunisation in accordance with the NHS Immunisation against infectious disease green book. Following the assessment the leaders implemented changes to ensure staff immunisation was kept in line with the green book.
• During the assessment we found staff had recorded the temperature of the vaccine fridge at 10.7 degrees each day in the temperature log for 3 weeks and no action was taken. This meant the vaccines could have been corrupted. Following the assessment the practice carried out a significant event investigation, contacted the appropriate agencies and took action to ensure this did not reoccur.
• The resuscitation equipment was not reviewed as recommended by the Resuscitation Council UK. During the assessment we were told the resuscitation equipment was carried out monthly, however the provider submitted further information to show this was checked weekly.
• The annual calibration of equipment was last carried out in May 2025. Following the assessment the practice carried out the calibration of equipment on 15 July 2026.
• The submission of unverified data from Interface Clinical Services relating to asthma, diabetes, and chronic kidney disease which highlighted possible concerns regarding monitoring was not accompanied by an action plan. Following the assessment the provider informed CQC an action plan was now in place.
• Leaders held regular meetings to address clinical concerns and risks, recording and sharing actions clearly, with the manager but these were not recorded. Following the assessment, the practice introduced regular meetings and began keeping meeting minutes.
• At the time of the assessment, staff had not completed care navigation training and there was no clear guidance in place to support the triage process. Following the assessment, staff completed care navigation training, and the practice implemented written triage and care navigation guidance.
• The practice was unable to demonstrate how it identified and addressed potential barriers to care or tailored support and treatment for people most likely to experience health inequalities. Following the assessment the practice provided a presentation to demonstrate how they had supported people to live healthy lives. This included supporting health, weight and diabetes prevention.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.