Background to this inspection
Updated
30 September 2021
Dr R Khanchandani’s Practice is located in Luton at:
The Blenheim Medical Centre,
9 Blenheim Crescent,
Luton,
Bedfordshire,
LU3 1HA.
The practice has a branch surgery at:
The Link Surgery,
10 Wetherne Link,
Hockwell Ring,
Luton,
Bedfordshire,
LU4 9PE.
The branch site was not visited as part of the inspection.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.
The practice is situated within the Bedfordshire, Luton and Milton Keynes (BLMK) Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 14,570. A GMS contract is a nationally agreed contract between general practices and NHS England for delivering general medical services to local communities.
The practice is a member of a primary care network (PCN) that enables them to work with other practices in the area to deliver care.
Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 45% Asian, 40% White, 10% Black, 4% Mixed, and 1% Other.
The practice has four male and two female GP partners and employs three salaried GPs, two male and one female. The nursing team consists of three practice nurses and one health care assistant, all female. There is a team of reception and administrative staff all led by a practice manager and supported by an operational manager. The practice is a training practice and currently has four GP registrars (GP registrars are qualified doctors training in general practice).
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
The practice is open at The Blenheim Medical Centre from 8am to 6.30pm Monday to Friday. The Link Surgery is open from 8am to 6.30pm Monday to Thursday and from 8am to 6pm on Fridays.
Routine appointments with a GP, practice nurse or health care assistant can also be booked through the practice for the Luton Extended Access Service. This service operates on Monday to Friday evenings from 6pm to 9pm and on Saturdays and Sundays from 8.30am to 2.30pm at two local GP Practices.
When the practice is closed out of hours services are provided by Herts Urgent Care and can be accessed via the NHS 111 service.
Updated
30 September 2021
We carried out an announced inspection at Dr R Khanchandani's Practice on 5 August 2021. Overall, the practice is rated as Requires Improvement.
The ratings for each key question are:
Safe - Good
Effective – Requires Improvement
Caring - Good
Responsive - Requires Improvement
Well-led - Good
We carried out an announced comprehensive inspection at Dr R Khanchandani's Practice on 12 March 2020. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our regulatory functions. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. We carried out an announced follow up inspection on 25 November 2020 to see if improvements had been made. The overall rating at the November 2020 inspection was requires improvement with inadequate for providing responsive services. Therefore, the service remained in special measures.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr R Khanchandani's Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection to follow up on:
- The five key questions: are services safe, effective, caring, responsive and well-led?.
- Any breaches of regulations or areas we identified at the previous inspection, where the provider should make improvements.
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.
We have rated this practice as Requires Improvement overall and for all population groups.
We rated the practice as good for providing safe services because:
- Improvements had been made to other systems, practices and processes in place to keep people safe.
- Staff vaccination records did not show documentary evidence that vaccines had been received and Patient Group Directions were not all current and appropriately authorised for staff to administer the medicines. However, immediately following the inspection, the practice provided evidence that appropriate actions had been taken to rectify the issues.
We rated the practice as requires improvement for providing effective services because:
- The practice had implemented measures to increase the uptake of cervical screening and childhood immunisations. There had been no new data published since the previous inspection to demonstrate the improvements made.
- Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
We rated the practice as good for providing caring services because:
- Staff dealt with patients with kindness and respect.
- Feedback from patients was positive regarding the care they received.
- The practice had measures in place to support carers and increased the number of patients identified as having caring responsibilities.
We rated the practice as requires improvement for providing responsive services because:
- Actions had been taken to improve patient satisfaction with the way they were able to access care and treatment in a timely way. There had been an improvement to some results of the National GP Patient Survey. However, the results remained lower than local and national averages.
- The practice identified learning from complaints and documented actions to prevent reoccurrence.
We rated the practice as good for providing well-led services because:
- Governance structures had improved, and the practice had developed a practice improvement plan to continue to make positive changes.
- Policies and procedures put in place were embedded in the practice.
- Staff were supported and were positive regarding the GP partners and practice management.
Whilst we found no breaches of regulations, the provider should:
- Obtain documentary evidence that staff have received appropriate vaccinations in line with current Public Health England (PHE) guidance if relevant to role.
- Have a system in place to manage Patient Group Directions (PGDs) so the information available is current and staff are authorised to administer vaccinations.
- Continue to take action to increase the uptake of cervical screening and childhood immunisations.
- Embed the changes made to improve patient satisfaction particularly in relation to access and appointment booking.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
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