A GP practice in Birmingham has been rated inadequate by the Care Quality Commission and has been placed in special measures, following an inspection in August.
This unannounced focused inspection took place at Dr Bharathi Chowdary Chaparala GP practice following whistleblowing concerns received regarding how safe the care and treatment being given to people was.
The practice was previously rated as good overall and for being safe, effective, caring, responsive and well-led. It is now rated as inadequate overall and for being safe, effective and well-led. Caring and responsive were not looked at during this inspection and remain rated as good.
Significant failings were found in people’s care, including safeguarding concerns not being addressed, medicine reviews not being completed effectively, concerns with the overall management of people’s long-term conditions and a lack of clinical oversight to ensure people were receiving adequate care and treatment.
Due to these failings, a temporary suspension of six months was imposed on the provider’s registration. This took effect from 7 September 2022. Currently another provider is running the service.
CQC has also placed the service in special measures. This means it is being kept under close monitoring.
Janet Ortega, CQC head of primary medical services inspection, said:
“When we visited Dr Bharathi Chowdary Chaparala GP practice, we found there was no effective leadership, and the provider didn’t have the capability to drive improvement in order to provide safe care and treatment to patients.
“The practice had no system in place to monitor potential safeguarding issues. We found evidence of neglect that hadn’t been followed up appropriately and vulnerable patients who hadn’t been identified as a safeguarding concern. Also, the ambulance service reported a safeguarding concern, which hadn’t been followed up by a clinician.
“Additionally, a child with safeguarding concerns had failed to attend a hospital appointment. No action had been taken to follow this up to check their wellbeing, as they could have been at serious risk.
“We will monitor the service closely and will return to check on progress. If we aren’t assured people are receiving safe care and treatment, we won’t hesitate to take further enforcement action.”
The inspection found:
- The practice had a list size of over 10,000 patients and one GP clinical lead. Staff carrying out advanced clinical roles were not being adequately supervised which placed patients at significant risk of harm
- The practice had no system in place to monitor potential safeguarding issues
- The practice did not have appropriate systems in place for the safe management of medicines. This included an ineffective system for the management of safety alerts, as actions had not been taken to ensure patients were informed of potential risks with certain medicines
- Patients on high risk medicines were not being monitored or reviewed regularly
- Medical records were not always accurate or up to date
- The practice was unable to demonstrate effective clinical supervision of staff carrying out clinical roles to ensure they were acting within their competencies
- The practice was unable to demonstrate that risk management plans and comprehensive risk assessments had been carried out for patients
- The practice culture did not effectively support high quality sustainable care
- The overall governance arrangements were ineffective. The practice did not have clear and effective processes for managing risks, issues and performance.