East Park Medical Centre - R P Pandya

Updated 10 February 2023

East Park Medical Centre – R P Pandya Medical Centre is located in Leicester City at:

264-266 East Park Road,

Leicester,

Leicestershire

LE5 5FD.

The practice has a branch surgery at:

41-43 Doncaster Road,

Leicester,

Leicestershire,

LE4 6JL.

East Park Medical Centre - R P Pandya is a training practice for trainee GPs.

During our inspection we visited both the main site located on East Park Road and the branch site located on Doncaster Road

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, surgical procedures and treatment of disease disorder or injury.

The practice offers services from both the main and branch sites. Patients can access services at either surgery.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, where appropriate 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 situated within the Leicester, Leicestershire and Rutland Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 10,400. This is part of a contract held with NHS England.

The practice is part of a wider network of five GP practices within Belgrave and Spinney Primary Care Network (PCN).

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 71.3% Asian 19.2% White, 4.5% Black, 2.2% White and 2.8% Others.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

There is a team of two GP partners and 7 long term locums who provide cover at both practices.

The practice has a team of two nurses who provide nurse led clinics for long-term conditions and use both the main and the branch locations.

The GPs are supported at the practice by a team of reception/administration staff. The Practice Manager is based at the main location and visits the branch location daily to provide managerial oversight.

The practice is open between 8 am to 6.30 pm Monday to Friday with the main site opening until 9pm on a Monday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally from within the practices Health Care Hub, where late evening and weekend appointments are available. Out of hours services are provided by DHU Healthcare.

Updated 10 February 2023

We carried out an announced inspection at East Park Medical Centre - R P

Pandya on 30 November 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective – requires improvement

Caring – good

Responsive - good

Well-led – requires improvement

Following our previous inspection in March 2022 the practice was rated as inadequate and was placed in special measures.

Due to the failings we identified in the management of patient care and treatment on the announced inspection March 2022, we issued 3 Warning Notices pursuant to Section 29 of the Health and Social Care Act 2008 in relation to Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment, Regulation 13 HSCA (RA) Regulations 2014 Safeguarding

service users from abuse and improper treatment and Regulation 17 HSCA (RA) Regulations 2014 Good governance.

This comprehensive inspection carried out in November 2022 covered all key questions to check compliance with the waning notices and to check on improvements made since the last inspection.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for East Park Medical Centre - R P Pandya on our website at www.cqc.org.uk

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

We found that:

• The practice had carried out a significant amount of work since the last inspection. Remote clinical searches identified that patients were receiving timely monitoring and follow up. Governance arrangements had improved both internally and with external parties. However, managers had not identified further issues and concerns highlighted during our November inspection visit prior to our site visit.
• Leaders demonstrated that they had the capacity and skills to delivery high quality sustainable care, but further work was required to allow them to identify emerging risk and embed systems and processes. For example: Further improvements were required in relation to fire safety, Legionella, emergency equipment, infection prevention and control, patient engagement and recruitment practices.
• The provider had improved governance arrangements, they had implemented systems and processes to support good governance. However, the systems and processes had not been in place long enough to develop, become embedded and be part of normal practice.
• The provider had not engaged with patients or staff to gather feedback. This meant they could not be assured development of services was appropriate for the practice population’s specific needs.
• The practice had not undertaken any form of analysis or review of the 2022 National GP Survey to develop any actions to address areas that were lower that national average.
• The provider had a mission and vision statement within their statement of purpose. However, staff, patients and external partners had not been involved in developing this and a strategy to monitor delivery was not in place.
• The provider had not ensured consistency of medication reviews, there was no standard documentation in use and they had not documented if patients had been involved.
• The provider did not have a process in place to review unplanned admissions and readmissions to secondary care.
• The provider had introduced a risk register for both sites with appropriate risks included, RAG rated and scored to identify seriousness with actions and timescales for completion in place. However, it had not yet been added to the governance agenda as a standing item and was not embedded within the practice.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Following out inspection in March 2022, the CQC took urgent action to issue warning notices to keep patients safe and the practice was put in special measures.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service. However, systems and processes needed embedding and strengthening. Requirement notices have been issued for Regulation 12 HSCA (RA) Regulations 2014 Safe care and Regulation 17 HSCA (RA) Regulations 2014 Good governance.

The practice will be kept under review and any future inspections will be carried out in line with our ongoing priority schedule.

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 Hospitals and Interim Chief Inspector of Primary Medical Services