The Care Quality Commission
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  • GP practice

Archived: Dr Satish Kumar Dhamija Also known as Lea Village Medical Centre

Overall: Requires improvement read more about inspection ratings

98-100 Lea Village, Kitts Green, Birmingham, West Midlands, B33 9SD (0121) 789 9565

Provided and run by:
Dr Satish Kumar Dhamija

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

All Inspections

30 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Satish Kumar Dhamija on 30 September 2016. This inspection was in response to our previous comprehensive inspection at the practice on 3 December 2015 where breaches of the Health and Social Care Act 2008 were identified. Previously the practice rated as inadequate overall, placed into special measures and we issued requirement notices to inform the practice where improvements were needed. The practice subsequently submitted an action plan to CQC detailing the measures they would take in response to our findings. The identified breaches found at the previous comprehensive inspection on 3 December 2015 related to the regulations Safe care and treatment; Good governance and Fit and proper persons employed. At our inspection on 30 September 2016 we found that the practice had made significant improvements. The requirement notices we issued following our previous inspection had both been met. The practice is now rated as requires improvement overall.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Blank prescription forms were not securely stored, nor was there a system in place to track these within the practice.
  • The treatment room containing a vaccination refrigerator was not locked we also found that the lock for the fridge contained the key.
  • Risks to patients were assessed and managed.
  • 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.
  • 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 urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management, however further improvements are still needed to ensure leadership and governance is sustained.
  • The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure the proper and safe management of vaccinations to prevent unauthorised access.

The areas where the provider should make improvement are:

  • Review arrangements for the security of prescription stationery.

  • Ensure a consistent approach in the process and the frequency of defibrillator checks.

  • Ensure the practice conducts monthly audits of vaccinations and conducts regular stock checks.

  • Review processes for the dissemination and accessibility of Patient Group Directions.

  • Review staff files to ensure personnel files contain evidence of appropriate identification checks

  • Review its processes to identify all the carers on the practice’s patient list.

  • Review its processes concerning contact with bereaved patients.

  • Review governance and leadership processes to ensure sustained improvement.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Satish Kumar Dhamija on 3 December 2015. Overall the practice is rated as inadequate.

Previously, the practice was first inspected on 01 November 2013 under the previous inspection methodology which identified three breaches:

  • Care and treatment was not always planned and delivered in a way that was intended to ensure patient's safety and welfare. Arrangements in place for dealing with medical emergencies were inadequate and were not in line with national guidance.
  • Systems in place did not ensure patients were cared for, or supported by, suitably qualified, skilled and experienced staff. Appropriate checks of people's character and experience were not undertaken or could not be evidenced.
  • The provider did not have effective systems in place to regularly assess and monitor the quality of service that patients receive. Patient’s views were not actively sought and regular audits were not undertaken to ensure the safety and quality of the service patients received.

The practice was then re-inspected for the above breaches on 13 May 2014 under the previous inspection methodology. This inspection found that the practice had still not made sufficient improvements with regards to two of the three previously identified breaches. These breaches related to unsatisfactory practice recruitment processes, inadequate assessment and monitoring of service quality for example through audits and not proactively seeking patient views.

The practice was the re-inspected for a third time on 21 August 2014 under the previous inspection methodology with regards to the above ongoing breaches and was found to have met standards required.

Our key findings across all the areas we inspected on 3 December 2015 were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment, a health and safety risk assessment was not available and the practice did not have an up to date fire risk assessment.
  • The practice had a number of policies and procedures to govern activity, but some contained limited information (with the business continuity plan also containing outdated information) and were inaccessible.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, learning was not effectively shared throughout the practice’ thorough enough to demonstrate learning.
  • A defibrillator was available on the premises. However was no evidence that it had been tested and checked to make sure it was ready for use.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients we spoke with and the comment cards we received were positive about their interactions with staff and said they were treated with compassion and dignity.
  • There was evidence that multi-disciplinary team meetings took place and that care plans were routinely reviewed and updated.
  • Limited clinical audits were carried out to demonstrate quality improvement with minimal action taken to improve patient outcomes. None of the clinical audits undertaken in the last two years were completed audit cycles where any changes made had been reviewed.
  • Information about how to complain was available and easy to understand.
  • Performance for mental health related indicators was above the national average (practice average of 100% compared to a national average of 89%). However the exception reporting in this area was above both CCG and national averages by between 10.3% and 21.5%.
  • Data from the Quality and Outcomes Framework (QOF) showed the practice was an outlier for the number of hypnotics prescribed, for lower levels of coronary heart disease prevalence than expected and low flu vaccination rates.

The areas where the provider must make improvements are:

  • Ensure risk to patients are assessed and action taken to mitigate such risks where appropriate. For example fire risk and emergency medications
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Review the schedule of both clinical and non-clinical audits in order to asses, monitor and improve the quality and safety of the service.
  • Have a robust system for sharing significant events and incidents to ensure lessons are learned and where appropriate further risks are mitigated.
  • Implement systems for seeking and acting on feedback received from patients in order to evaluate and improve services.

In addition the provider should:

  • Review and update policy, procedures and guidance where required.
  • Review the disability assessment to ensure all appropriate arrangements are in place to enable access such as the use of a hearing loop for patients with hearing difficulties.
  • Ensure that accurate information regarding opening times is available to all patients.
  • Ensure that the business continuity plan is in place sufficiently detailed to be effective if necessary
  • Consider the benefits of actively using the carers register to support and improve patient care and welfare
  • The practice should ensure that they audit the use of hypnotics to determine reasons behind the large variation in prescribing.
  • Review the arrangements and policy for emergency medicines and equipment, ensuring they are accessible and staff are aware of their location.

I am placing this practice in special measures. Where a practice is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 August 2014

During an inspection looking at part of the service

At our last inspection in May 2014, the provider did not have a robust recruitment process to provide assurance that only suitable staff were employed at the practice. The provider did not have an effective system to regularly assess and monitor the quality of service that patients received or identify, assess and manage risks to the health, safety and welfare of patients who used the service and others. We set compliance actions and told the provider to improve.

The purpose of this inspection was to see if improvements had been made since our last inspection in May 2014. We gave the provider short notice of our inspection so that any disruption to patient's care and treatment were minimised. During the inspection we spoke with five members of staff, this included the practice manager and the lead GP who was also a partner at the practice. We also spoke with four patients. We found that the provider had made the necessary improvements.

There were arrangements in place to deal with foreseeable medical emergencies.

Procedures were in place to ensure that appropriate checks were made before staff began working at the practice.

The provider had improved the system in place for monitoring the quality of service provision and identifying, assessing and managing risks to the health, safety and welfare of patients who used the service and others. Most of the patients who we spoke with were happy with the care and treatment they received. However, some patients told us of areas that they thought the practice could improve on and said that they had received surveys to give their feedback.

13 May 2014

During an inspection looking at part of the service

At our last inspection in November 2013, we found that arrangements for dealing with medical emergencies were inadequate. Recruitment processes for ensuring suitable staff were employed were not robust and systems for monitoring the quality of the service provided were not well established. At the time of the inspection, we judged that this had a moderate impact on people who used the service. We set compliance actions and told the provider to improve.

The purpose of this inspection was to see if improvements had been made since our last inspection in November 2013. We gave the provider short notice of our inspection so that any disruption to people's care and treatment were minimised. During the inspection we spoke with five people who used the service. We also spoke with five members of staff. This included the GP who was the registered provider, the practice manager, the assistant manager and two reception staff. The provider sent us an action plan following our last inspection which recorded the actions taken to address the issues raised. However, we found that not all of the areas of improvements identified at the previous inspection had been fully addressed.

The people who we spoke with on the day of the inspection gave mixed views on the quality of the service. Some people told us that the quality of service was very good. One person told us, "The staff are very good, I have no concerns". Other people commented that sometimes it was difficult to get appointments. One person told us, "It can be difficult to get an appointment as by the time you get through to the practice the appointments have all gone".

There were arrangements in place to deal with foreseeable emergencies.

The provider did not have a robust recruitment process to provide assurance that only suitable staff were employed at the practice.

The provider did not have an effective system to regularly assess and monitor the quality of service that people received or identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

1 November 2013

During a routine inspection

As part of our inspection we spoke with six patients who used the service. We also spoke with five members of staff. This included the GP, the practice manager and three reception staff.

Patients spoken with were generally satisfied with the care and treatment they received at the practice. They told us that any care and treatment they received was with their agreement and that their health care needs were kept under review. One patient told us, 'I have high blood pressure and I take medication for that. They see me every so often to keep an eye on me. They are pretty good like that.' Another patient told us, 'On the whole I have always been satisfied with the service.'

Patients were protected from the risks associated with medicines. Prescriptions were available when needed and medicines were stored appropriately. However, not all patients on long term medication could recall having received regular reviews of their medicine.

We found that arrangements for dealing with medical emergencies were inadequate; Recruitment processes for ensuring suitable staff were employed were not robust and systems for monitoring the quality of the service provided were not well established. Patients had little opportunity to feedback their views of the service.