Archived: Drs Sidhu & Batra Also known as Chancery Lane Surgery

We carried out an announced focused inspection at Drs Sidhu & Batra also known as Chancery Lane Surgery on 12 September 2022. Overall, the practice is rated as requires improvement.

Safe – Requires Improvement

Effective - good

Well-led – Requires Improvement

Following our previous inspection on 17 February 2015, 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 Drs Sidhu & Batra on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was a focussed inspection and looked at:

• The key questions inspected: are services safe, effective and well-led.

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 included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• The practice were an outlier for some prescribing indicators. They worked with the Integrated Care Board (ICB) medicines team to make monitor and make improvements with prescribing.
• Patients received effective care and treatment that met their needs. Processes were in place to monitor patients’ health in relation to the use of medicines including high risk medicines. However, we found some patients were overdue a review.
• There were shared care agreements in place with secondary care providers for patients prescribed high risk medicines. Shared care guidelines were followed. However, blood test results were not always added to the patients’ records.
• Safety alerts were received by the practice. A review of the patient record system found some patients required a review when prescribed a combination of medicines. The practice immediately contacted these patients and invited them in for a review.
• There was a significant event process in place that demonstrated the practice learned and made improvements when things went wrong.
• The practice had recruited a clinical scientist who was responsible for carrying out clinical audits and searches of the patient record system to ensure patients were reviewed and monitored according to current guidelines. At the time of the inspection they were new to their role and second cycle audits had not yet been completed.
• The published cervical cancer screening showed that the practice had not met the target of 80% set by the UK Health and Security Agency. The practice had taken actions to improve the uptake of cervical screening.
• The practice used policies and procedures to govern their work. However, there was a lack of clinical oversight to ensure policies and procedures regarding medicines management and effective management of patients was applied.
• The processes for managing risks, issues and performance were not always clear and effective.
• The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles. Staff who wished to develop were offered opportunities to undertake additional training.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The practice had a strategy and business plan in place. This included a move to a new purpose built building within the near future. They had planned to develop their service and provide space for community, mental health and pharmacy services to work from the same building.
• Staff reported they felt supported by the GP partners and practice management.

We found a breach of regulations. The provider must:

• 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:

• Continue to take measures to improve the uptake of cervical screening.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services