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The provider of this service changed - see old profile

We are carrying out a review of quality at Witham Health Centre. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection summaries and ratings from previous provider


Overall summary & rating

Requires improvement

Updated 10 July 2019

We carried out an announced comprehensive inspection at PK Mohanty & Partners, known as the Witham Health Centre on 30th May 2019 as part of our inspection programme. This practice was previously rated requires improvement when we carried out inspections in April 2017 and in March 2018.

At the previous inspections, we found breaches of the regulations in relation to the management of high-risk medicines, the availability and storage of emergency medicines, learning from significant events and low patient satisfaction in relation to the GPs working at the practice.

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 have rated this practice as requires improvement overall.

We rated the practice as good for providing caring, responsive and well led services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for safe services because:

  • On the day of the inspection we found that checks for the high-risk medication Lithium were not being carried out.
  • Although safety alerts were received and distributed these were not acted upon.
  • There was no book for the recording of controlled drugs.
  • Fire training was outdated for some staff.
  • No infection control audit had been carried out.
  • PAT Testing had expired.
  • The training for infection control had expired for the infection control lead.

We rated the population groups long-term conditions, working age people and those experiencing poor mental health as requires improvement because:

  • The clinical outcome indicators for 2017/2018 for people with long term conditions and those experiencing poor mental health was below local and national averages. Although the unverified data from 2018/2019 showed an upward trend in some areas these figures were still below the national averages and there had been a downward trend since our initial inspection in 2017.
  • Cancer data was lower than local and national averages in some areas.

The cumulative effect of rating three population groups in this way meant that the effective domain was rated as requires improvement.

The areas where the practice must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the practice should make improvements are:

  • Ensure training of staff is kept up to date including fire and infection control.
  • Continue to monitor and review the prescribing of antibiotics and hypnotics and all high-risk medicines.
  • Continue to strengthen and monitor improvement relating to patient satisfaction.
  • Monitor and review bowel cancer screenings and the number of new cancer cases treated which resulted from a two week wait (TWW) referral.
  • Review current systems and process to identify carers to ensure they receive appropriate support.
  • Review the guidance and legislation in relation to the storage and issue of controlled drugs in use at the practice, to ensure they are being followed.

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

Dr Rosie Benneyworth BM BS BmedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

Inspection areas

Safe

Requires improvement

Effective

Requires improvement

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Good