The Care Quality Commission
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Archived: Drs Shrivastava & Raolu

Overall: Good read more about inspection ratings

Maltby Services Centre, Braithwell Road, Maltby, Rotherham, South Yorkshire, S66 8LE

Provided and run by:
Drs Shrivastava & Raolu

All Inspections

23 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Shrivastava and Raolu on 12 January 2016. The overall rating for the practice was good but with requires improvement for safety. The full comprehensive report for the 12 January 2016 inspection can be found by selecting the ‘all reports’ link for Drs Shrivastava and Raolu on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 23 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 12 January 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Good.

Improvements had been made since our last inspection on 12 January 2016. Our key findings were as follows:

  • Recruitment procedures had been improved. Disclosure and barring Service (DBS) checks and references had been obtained prior to employment. We also found DBS checks for staff who acted as chaperones and staff vaccination and immunity status checks had been obtained since the last inspection.

  • Health and safety procedures had been improved. Control of substances hazardous to health and sharps injuries risk assessments had been developed and implemented. Staff had received training in fire safety and infection prevention and control (IPC). The IPC procedure had been updated.

  • Processes to ensure staff had appropriate medical indemnity insurance had been improved. Staff had medical indemnity insurance in place and the practice had also implemented records to enable the practice to monitor that their insurance was up to date.

  • Staff told us they felt  more involved in discussions about how to run and develop the practice and regular practice meetings had been held.

  • Clinical supervision had been provided since the last inspection and regular practice nurse meetings had been implemented since the beginning of 2017.

The areas where the provider should make improvement are:

  • At our last inspection on the 12 January 2016 we found the practice had a defibrillator. This equipment was shared with a  neighbouring practice and was held in a shared utility room. We observed that the equipment was stored in a box which was labelled, however a clipboard had been placed on the box and the label was hidden so the equipment may not have been easy to locate in an emergency. At this inspection we observed a similar situation with a box obscuring the label. This arrangement should be reviewed with the other practice to ensure this equipment is clearly displayed.

  • At our last inspection on 12 January 2017 we found staff induction was not recorded. At this inspection, the practice manager told us staff induction was not recorded although staff told us induction had been recorded for the most recently employed member of staff. Evidence of induction records could not be provided on the day of inspection as the member of staff who held these was off duty. They told us these would be provided following the inspection but at the time of writing the report CQC had not received a copy of the document. The processes for recording induction should be reviewed and applied consistently and records should be available.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shrivastava and Raolu on 12 January 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and managed. However, the risk assessments to manage health and safety matters did not identify all the hazards and the control measures in place. Not all the staff had received training in matters relating to health and safety.
  • Appropriate recruitment checks had not always been undertaken prior to employment. The nursing team did not have medical indemnity cover.
  • 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. However, there were no records of induction and clinical supervision on staff files.

  • 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.
  • Patients said they found it easy to make an appointment with a named GP and that 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. The practice took account of 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:

  • Appropriate recruitment checks had not always been undertaken prior to employment.

  • Systems and processes were not in place to ensure relevant staff had appropriate medical indemnity insurance in place as required by The Health Care and Associated Professions (Indemnity Arrangements) Order 2014.

  • The risk assessments to manage health and safety matters did not adequately or accurately identify and describe all the hazards and the control measures in place.

  • Not all staff had received mandatory training such as infection prevention and control (IPC) and fire safety.

The areas where the provider should make improvement are:

  • Procedures did not include arrangements for training and disclosure and barring service checks for staff who act as chaperones.

  • The IPC protocol was not up to date.

  • There was no record of staff vaccination or immunity status and this had not been checked.

  • The emergency equipment may not always be easily located due to its storage location.

  • Induction and clinical supervision was not recorded.

  • Not all the staff felt they were involved in discussions about how to run and develop the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice