The Care Quality Commission
  • Doctor
  • GP practice

Archived: 271a Southend Road

Overall: Good read more about inspection ratings

271A Southend Road, Stanford Le Hope, Essex, SS17 8HD (01375) 679316

Provided and run by:
Dr Anand Manohar Deshpande

Important: The provider of this service changed. See new profile
Important: The provider of this service changed. See old profile

All Inspections

31 May 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at 271a Southend Road on 31 May 2023. Overall, the practice is rated as Good.

Safe - Good

Effective – Good

Responsive – Good

Well-led - Good

Following our previous inspection in August 2022, the practice was rated requires improvement overall. The practice was rated inadequate for providing safe services, requires improvement for providing effective and well – led services and good for providing caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for 271a Southend Road on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection to follow up on concerns from our previous inspection in August 2022.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

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.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • 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.

In August 2022, we rated the practice Requires Improvement overall.

We previously found that:

  • There were systems in place for the safeguarding of vulnerable adults and children, however not all staff had received safeguarding training appropriate to their role.
  • There was a lack of risk assessments in place to identify and take action to mitigate risks.
  • There was a lack of assurance that patients received appropriate monitoring of their medication and medical condition.
  • Patients did not always receive care and treatment in line with guidelines.
  • The practice had not met the 90% minimum target for childhood immunisation uptake for children aged five, however the practice had met the 95% WHO based target for childhood immunisations for children aged one and two.
  • There was a lack of assurance that staff had received relevant training at an appropriate level to perform their role.
  • Large parts of the governance structure were reliant on one member of staff, other staff found it difficult to access information in their absence.
  • There were gaps in the effectiveness of governance arrangements which impacted on the safety of patients and staff.

In May 2023, we rated the practice Good overall.

We found that:

  • There were processes in place for the safeguarding of vulnerable adults and children, all staff had received safeguarding training appropriate to their role.
  • There was a number of environmental risk assessments in place. Concerns identified has been actioned to mitigate risks.
  • The practice had improved and embedded their monitoring systems for patients being prescribed medication. We found the practice had taken action to review patients in line with national guidance. The practice continued to improve the system to code medical conditions on patients records to ensure all patients received the relevant monitoring. We were assured that the systems in place kept patients safe.
  • The practice had continued to encourage patients to attend childhood immunisations.
  • We found that all staff had completed annual appraisals.
  • The practice had systems in place to monitor that staff had received appropriate training to perform their role.
  • The practice had implemented processes to ensure that information was accessible to all leaders.
  • Governance arrangements had been reviewed to ensure the safety of patients and staff.
  • The practice had a system in place to deal with patient safety alerts.
  • Staff found leaders approachable and felt the practice worked together as a team.

Whilst we found no breaches of regulations, the provider should:

  • Continue to improve the uptake childhood immunisations and national cancer screening.
  • Strengthen systems to ensure patient records are coded correctly.
  • Continue to carry out appraisals for all staff members.
  • Increase engagement of the patient participation group.

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 Health Care

11 January 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at 271a Southend Road on 11 January 2023. The practice was not rated at this inspection. This inspection was to follow up on breaches of the regulations identified at the previous inspection in August 2022 where we rated the practice as requires improvement overall. Specifically, we rated the safe key question as inadequate, effective as requires improvement, caring and responsive as good and well-led as requires improvement.

As a result of the findings from that inspection we issued the practice with a warning notice for improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for 271A Southend Road on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up a warning notice from the previous inspection.

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:

  • 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

We found that:

The practice had complied with the warning notice;

  • There were now policies, protocols and risk assessments for infection prevention and control procedures were in place.
  • Where emergency medicines recommended by guidance were not being stored an appropriate risk assessment was in place.
  • The systems for managing medicines had improved and patients were safe.
  • Patients received effective care which met their needs.
  • The system for ensuring patients received appropriate care and treatment had improved, specifically relating to chronic kidney disease, hyperthyroidism and patients with diabetic retinopathy with a higher blood glucose monitoring test.
  • The processes for monitoring patients’ health in relation to the use of medicines had improved.

Whilst we found no breaches of regulations, the provider should:

  • Continue to embed medicines management processes.
  • Continue to embed processes relating to reviewing patients in line with evidence-based practice.
  • Improve coding processes and patient records so the patient record accurately reflects care and treatment decisions, especially for patients requiring a steroid emergency treatment card.

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

04 August 2022

During an inspection looking at part of the service

We carried out an announced inspection at 271a Southend Road on 04 August 2022. Overall, the practice is rated as Requires Improvement.

Safe - Inadequate

Effective – Requires improvement

Well-led - Requires improvement

Following our previous inspection on 28 November 2018, the practice was rated Good overall and for all key questions.

The data and evidence we reviewed in relation to the responsive and caring key questions in planning for this inspection did not suggest we needed to review the ratings, therefore the service retains the previous rating of good for these key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for 271a Southend Road on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

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
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Requesting staff complete questionnaires
  • Requesting the practice signpost patient to our website to complete ‘Give Feedback on Care’ forms for this 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 and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall

We found that:

  • There were systems in place for the safeguarding of vulnerable adults and children, however not all staff had received safeguarding training appropriate to their role.
  • There was a lack of risk assessments in place to identify and take action to mitigate risks.
  • There was a lack of assurance that patients received appropriate monitoring of their medication and medical condition.
  • Patients did not always receive care and treatment in line with guidelines.
  • The practice had not met the 90% minimum target for childhood immunisation uptake for children aged five, however the practice had met the 95% WHO based target for childhood immunisations for children aged one and two.
  • There was a lack of assurance that staff had received relevant training at an appropriate level to perform their role.
  • Large parts of the governance structure were reliant on one member of staff, other staff found it difficult to access information in their absence.
  • There were gaps in the effectiveness of governance arrangements which impacted on the safety of patients and staff.
  • The practice had a system in place to deal with patient safety alerts.
  • Staff found leaders approachable and felt the practice worked together as a team.

We found two breaches of regulations. The provider must:

  • 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 provider also should:

  • Continue to improve the uptake of the measles, mumps and rubella immunisation for children aged five.
  • Continue to improve the uptake of cervical cancer 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

28/11/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating October 2017 – Requires improvement overall particularly safe, effective and well-led.)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at 271a Southend Road on 28 November 2018 as part of our inspection programme to follow up on concerns found at the previous inspection.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The practice had implemented an effective system to monitor patients being prescribed high risk medicines.
  • The practice had completed actions required from the infection control audit. We found there was a proactive approach to risk assessments however one action had not been completed from the fire risk assessment. Since the inspection the practice had implemented a system to ensure alarm checks were documented.
  • Staff understood their responsibilities to manage emergencies on the premises. Clinicians knew how to identify and manage patients with severe infections including sepsis. However, we found that non-clinical staff members were unable to recognise patients with suspected sepsis. The practice did not have the appropriate medicine or equipment to deal with sepsis or other potential medical emergencies.
  • We generally found that care plans were completed appropriately however we found that in some cases mental health and dementia care plans were incomplete.
  • QOF data published in 2017/18 found the practices clinical performance indicators for patients with long term conditions and mental health were below local and national averages. The practice was aware of their clinical performance and had implemented a process that had improved their performance indicators to a satisfactory level.
  • We found there was an ineffective system to review patients with gestational diabetes in line with NICE guidance.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice had acted on patient feedback they had received. They had changed the appointment system and patients reported greater satisfaction since the change.
  • The practice had a strong focus on implementing technology to improve treatment and to support patients’ independence.
  • There was a focus on continuous learning and improvement at all levels of the organisation. Staff were encouraged to share responsibilities and develop their roles.

The areas where the provider should make improvements are:

  • Continue to develop systems to monitor clinical performance and patient outcomes for patients with long-term conditions and those suffering with poor mental health.
  • Strengthen the system to review patients with gestational diabetes in line with NICE guidance.
  • Improve systems and process to manage medical emergencies such as sepsis.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

16 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of 271a Southend Road on 16 October 2017. Overall the practice is rated as requires improvement.

Our key findings across all areas we inspected were as follows:

  • Staff were able to recognise and reported significant incidents. We saw that actions, learning and follow up was documented.

  • The practice had some clearly defined and embedded systems, processes and practices in place to minimise risks to patient safety. However there were actions from risk assessments and audits that had not been completed.

  • The process for monitoring high risk medicines was not effective. We viewed a sample of records from searches of patients that were prescribed a high risk medicine and saw that reviews and monitoring was not in place for these patients.

  • Blank prescription forms and pads were securely stored. The practice were recording the serial numbers but had not been tracking the prescriptions through the practice. This was changed the day of the inspection and the practice forwarded a copy of their new process and record sheet to document this.

  • The practice had an overarching governance framework to support the delivery of the strategy and good quality care.Procedures and policies had been reviewed and updated. However, there was an inconsistent system for identifying, capturing and managing issues and risks.

  • The practice sought feedback from staff and patients and we saw examples where feedback had been acted on. However, the practice did not have a patient participation group.

  • Medicine and patient safety alerts had been actioned.We saw that the practice had a folder of all safety alerts that had been received. The practice produced evidence of searches already conducted in response to the alerts received.

  • The practice were utilising the community specialist nursing teams to manage some of the patients with long term conditions. In addition to this staff that were working in the practice were completing reviews, immunisations and health screening. They were telephoning patients that were hard to engage.

  • The practice had implemented clinical audit and we saw evidence of quality improvement.

  • The practice had locum packs and checklists in place for locum recruitment. All patients had a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

  • The practice had a comprehensive business continuity plan for major incidents such as power failure or building damage. The plan included arrangements for cover from local practices in the area should there be the need.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients including the prescribing of high risk medicines.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, completing actions identified from infection control audits and risk assessments and ensuring there are systems in place in order to provide patient care in relation to the monitoring of patient’s health conditions.

In addition the provider should:

  • Implement the procedure to ensure prescriptions are tracked throughout the practice.

  • Continue to work to establish a Patient Participation Group.

  • Review PGDs and ensure all are signed by GP in line with legislation.

  • Continue to seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services. For example telephone access.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice