This practice is rated as Requires Improvement overall.
The key questions at this inspection are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires Improvement
The full comprehensive report can be found by selecting the ‘all reports’ link for Dr Prathap Jana on our website at www.cqc.org.uk.
Why we carried out this inspection:
We carried out an announced inspection at Dr Prathap Jana on 20 May 2022 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
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 in line with all data protection and information governance requirements.
This included:
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Requesting evidence from the provider
- A short site visit
Our judgement of the quality of care at this service is based 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.
Our findings:
We have rated this practice as Requires Improvement overall.
- The practice’s systems, practices and processes did not always keep people safe and safeguarded from abuse.
- Improvements were required to infection prevention and control systems and processes.
- Risks to patients, staff and visitors were not always assessed, monitored or managed effectively.
- The arrangements for managing medicines did not always keep patients safe.
- Improvements were required to some types of patient reviews.
- Performance in relation to some cancer screening required improvement.
- Some governance documents we looked at were not up to date.
- Processes for managing risks, issues and performance required improvement.
The areas where the provider 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 provider should make improvements are:
- Consider revising practice systems to formally record the monitoring of patient referrals to other services under the two week wait system.
- Consider revising practice systems to include reference to the ombudsman in the complaints policy.
- Continue with plans to recruit patients to the practice’s Patient Participation Group (PPG).
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Please refer to the detailed report and the evidence tables for further information.