5 July 2023
During a routine inspection
We carried out an announced inspection at Dr Pritpal Bath on 21 July 2022. Overall, the practice is rated as good.
Safe - requires improvement
Effective - good
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 21 July 2022, the practice was rated inadequate overall and inadequate for the safe and well-led key questions and requires improvement for providing effective services. The practice was placed into special measures. As a result of the concerns identified during our inspection in July 2022, we issued a Section 29 warning notice in relation to a breach of Regulation 12 Safe Care and Treatment.
We undertook a focused inspection on 6 October 2022 to check that the practice had addressed the issues in the warning notice. During our inspection in October 2022 we found that the requirements of the warning notice had been met.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Pritpal Bath on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this announced comprehensive inspection to follow up breaches of regulation from our previous inspection in July 2022.
We inspected the safe, effective, caring, responsive and well-led key questions following a period of special measures, and followed up on breaches of regulations and ‘shoulds’ identified in our previous inspection in July 2022.
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:
- Conducting staff interviews using video conferencing.
- 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, patients, the public and other organisations.
We found that:
- The practice systems and processes to keep people safe were not effective across all areas.
- Appropriate monitoring of standards of cleanliness and hygiene were being met.
- There were adequate systems to assess, monitor and manage risks to patient safety.
- Systems for the appropriate and safe use of medicines, including medicines optimisation were effective in most cases.
- There was a consistent approach towards managing and learning from incidents.
- Patients’ needs were assessed, and care and treatment was delivered in line with care pathways in most cases.
- There was a programme of quality improvement activity.
- The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Staff were consistent and proactive in helping patients to live healthier lives.
- People were able to access care and treatment in a timely way.
- Leaders had sufficient risk management and governance arrangements to ensure safe, high quality and sustainable care was delivered.
- The practice involved the public, staff and external partners to sustain high quality and sustainable care.
- The practice had made significant improvements across the majority of the practice in response to our previous inspection.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Take action to regularly audit the looked after children register.
- Embed the changes made to ensure test results are routinely recorded in the patient record.
- Take action to improve the system of auditing previous safety alerts.
- Take action to improve the documentation of care and treatment for patients with long term conditions and potential missed diagnosis is followed up appropriately.
- Improve the uptake of cervical cancer screening.
- Take action to keep the carers’ register up-to-date.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service. We encourage the practice to sustain and embed the improvements.
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