The Care Quality Commission
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  • GP practice

Wood Street Health Centre - Dr. Raghav Prasad Dhital

Overall: Good read more about inspection ratings

6 Linford Road, Walthamstow, London, E17 3LA (020) 8430 7750

Provided and run by:
Wood Street Health Centre - Dr. Raghav Prasad Dhital

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Wood Street Health Centre - Dr. Raghav Prasad Dhital on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Wood Street Health Centre - Dr. Raghav Prasad Dhital, you can give feedback on this service.

08 May 2019

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection of Wood Street Health Centre - Dr. Raghav Prasad Dhital on 20 September 2018. At the inspection, we rated the practice as good overall, but as requires improvement for providing well-led services because:

  • Some policies and procedures were not practice specific and did not contain all the necessary information.
  • There was a backlog of patient documents which needed to be scanned on to the system.
  • Patient information was not secure as there were two boxes of unlocked patient records in the reception area which was shared with other practices.

The full report of the September 2018 comprehensive inspection can be found by selecting the ‘all reports’ link for Wood Street Health Centre - Dr. Raghav Prasad Dhital on our website at www.cqc.org.uk.

We carried out an announced focused inspection of Wood Street Health Centre - Dr. Raghav Prasad Dhital on 8 May 2019 to check whether the practice was providing well-led care.

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.

At this focused inspection on 8 May 2019 we found the provider had taken action to address the issues identified.

We have rated this practice as good overall.

We have rated the practice as good for providing well-led services because:

  • The practice had purchased four additional lockable cabinets in which to store patient records securely.
  • A new system had been implemented to ensure the prompt scanning of patient information.
  • Policies and procedures had been reviewed and were specific to the practice.

We also found the practice had acted upon suggested areas of improvement from the previous inspection, as follows:

  • The practice had purchased paediatric oximeters for clinicians to use if needed.
  • All staff, including non-clinical staff members, had completed sepsis awareness training. A sepsis policy had been produced, which identified the practice lead for sepsis and included symptoms for staff to be aware of.
  • The practice had carried out its own patient survey, the results of which were positive about the service and staff. The results had been collated and were due to be discussed with the Patient Participation Group (PPG) in June 2019.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

20 September to 20 September 2018

During a routine inspection

This practice is rated as good overall.

(Previous rating in July 2017 was requires improvement overall, requires improvement for safe, effective, caring, responsive and well-led and requires improvement for all of the population groups.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Wood Street Health Centre - Dr. Raghav Prasad Dhital on 20 September 2018 to follow up on the breaches of regulation found on the inspection on 17 July 2017.

At this inspection we found although the practice had responded to the findings of the previous report, the provider needed to make further improvements. For example, some of the policies and procedures did not fully reflect the practice, and there were gaps in the management and security of patient documents.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice had systems to keep clinicians up to date with current evidence-based practice.
  • The provider was aware of the requirements of the duty of candour. They had instigated a new system to ensure they captured all incidents that may have constituted a duty of candour.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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:

  • The provider should review the necessity for child oximeters for the monitoring a child’s pulse and heart rate.
  • The provider should review the necessity for the practice to carry out its own patient satisfaction survey.
  • The provider should consider where reception staff would benefit from training to enable them to recognise the signs of sepsis.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

19 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wood Street Health Centre – Dr Raghav Prasad Dhital on 23 February 2016. The overall rating for the practice was requires improvement. The full comprehensive report published in January 2017 can be found by selecting the ‘all reports’ link for Wood Street Health Centre- Dr Raghav Prasad Dhital on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 19 July 2017, carried out to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 23 February 2016. There were breaches in medicines management, infection control, governance and audit arrangements. There were also concerns with practice policies and procedures, identifying carers, staff training, health and safety and the business continuity plan. This report covers our findings in relation to those requirements and also additional improvements/deteriorations made since our last inspection.

Overall the practice is still rated as requires improvement.

Our key findings were as follows:

  • The review process and learning outcomes for significant events were not always effective or followed through and the policy did not highlight how to deal with events that did not need to be externally reported.

  • There was a safeguarding policy, but this did not highlight who the practice leads were and there were discrepancies about the correct external contact numbers and where the numbers were located.

  • The practice had arrangements to deal with medical emergencies and major incidents; however there was confusion amongst staff as to where the defibrillator was kept. The oxygen cylinder was extremely heavy and no consideration was taken into account for how to manoeuvre it in the event of an emergency.

  • The practice had an induction process however this had not been used for newly appointed staff members and appraisals were not comprehensive.

  • The business continuity plan was incomplete and only consisted of a list of contact telephone numbers.

  • The practice could not demonstrate that the duty of candour was always adhered to.

  • There was no formal system for actioning patient safety alerts.

  • The practice did not have a comprehensive compliment of practice specific policies and not all staff members were able to locate the policies on the computer system.

  • There were no formal care plans for patients.

  • The practice had identified less than 1% of the patient list as a carer.

  • There was no practice website.

  • Practice staff had completed mandatory training but there was no system for ensuring that this remained up to date.

  • Five out of six reception staff members who acted as a chaperone had received a Disclosure and Barring Service (DBS) check.

  • The practice held extended hours appointments on one evening a week until 8pm and was a part of the local HUB which provided weekday and weekend appointments when the practice was closed.

  • Clinical audits demonstrated quality improvement.

  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

  • GPs had a good understanding of the mental capacity act.

  • Information about services and how to complain was available and this was discussed regularly at practice meetings.

  • Patient Group Directions (PGD) had been adopted by the practice to allow nurses to administer medicines in line with legislation.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Act in accordance with the Duty of Candour.

  • Ensure all premises and equipment used by the service provider is fit for use.

  • Ensure the most recent CQC rating is clearly displayed.

  • Ensure care and treatment is provided in a safe way to patients.

In addition the provider should:

  • Review the system for identifying carers to enable improved support and guidance to be provided to them.

  • Review the process for formalising patients care plans.

  • Review the system for carrying out staff inductions and ensuring staff training remains up to date.

  • Work to increase the uptake of childhood immunisations.

  • Review the system in place for cervical cytology to include a failsafe.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 February 2016

During a routine inspection

We carried out an announced comprehensive inspection at Wood Street Health Centre on 23 February 2016. Overall the practice is rated as requires improvement.

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

  • Risks to patients were not robustly assessed and managed. For example the practice could not demonstrate that legionella testing had been carried out, however evidence was provided post inspection that this had been done and was the responsibility of the health centre. Basic life support training was out of date having last been completed in February 2013.
  • The practice did not have adequate stocks of emergency medicine to reasonably meet expected emergency situations, there were three emergency medicines available, adrenaline, diazepam and atropine. The paracetamol was out of date.
  • The oxygen masks were out of date and there was no system for checking the oxygen was full and in working order.
  • There had been four clinical audits carried out in the past two years, none of which were completed audits where improvement to patient care could be demonstrated.
  • Not all actions identified from the infection control audit carried out in December 2013 had been actioned and non-clinical staff members had not received infection control training.
  • The children’s safeguarding policy did not include details of who to contact for further guidance if staff were concerned about a patient’s welfare.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However we saw that not all Patient Group Directions were signed or in date.
  • Regular fire alarm testing and fire drills were carried out but staff members had not received fire training.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with a walk in clinic and urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review.

The areas where the provider must make improvement are:

  • Mitigate risks associated with not having emergency medicines to deal with a range of medical emergencies, develop a system for checking medicines and equipment are in date and in working order to ensure the are ready for use.

  • Carry out clinical audits and re-audits to improve patient safety and outcomes.
  • Mitigate risks associated with not having risk assessments for fire, legionella and infection control.

  • Ensure Patient Group Directives are signed by both the GP and Nurse as well as ensuring they are in date.

The areas where the provider should make improvement are:

  • Review and update the practice’s procedures and policies.

  • Review the child safeguarding policy to include who to contact for further guidance.

  • Review the system for identifying carers to enable improved support and guidance.

  • Ensure vulnerable adult training is completed by staff members.

  • Review systems to ensure all mandatory training is carried out in the specified time scales.

  • Maintain the business continuity plan to ensure that it meets the needs of the practice in the event of an emergency.

  • Maintain a comprehensive understanding of the health and safety checks carried out by the Health Centre that are relevant to the practice.

from the Chief Inspector of General Practice

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

15 August 2013

During a routine inspection

We spoke to two doctors at the practice and both told us they would give patients information regarding their condition and possible treatment options in a way they could understand.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. All the patients we spoke with told us they were happy with the care they received. Comments included 'I'm absolutely happy with the service, I couldn't fault it', 'I am happy with the information they give me, I feel listened to' and 'I don't mind who I see, they all give me time and explain what's wrong.'

We were told that one member of staff was the safeguarding lead for the practice. This person was able to give advice to other staff should they have any safeguarding concerns. All staff we spoke with knew who the practice lead was.

Staff received appropriate professional development. All the staff we spoke with said that they felt well supported. They said the practice manager and doctors were approachable and always happy to discuss any issues with them

People were made aware of the complaints system. When people registered they were given an information leaflet outlining how to make a complaint.