Dr PV Gudi and Partner

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection, we found that not all safety alerts were actioned appropriately, processes for the management of pathology results and clinical correspondence needed strengthening to ensure they were actioned appropriately and some patients had not received medicine reviews. At this inspection we found improvements had been made, with processes in place to ensure there were effective systems for the management of safety alerts and correspondence and this was being routinely reviewed and monitored. During the remote clinical searches we found some patients required monitoring, however following the assessment, we received evidence to demonstrate that actions had been taken to review the patients we had identified. We found action had been taken to ensure people’s safety was integral to the care and treatment they received. All staff understood the importance of keeping people safe and where there were concerns identified about people’s safety these were actioned promptly.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice had a significant events lead responsible for supporting staff in identifying and reporting significant events. The practice followed their significant events policy and discussed events and incidents during team meetings and learning was shared with staff. The practice had a duty of candour policy and involved people when managing significant events and errors. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed; we found the practice responded to people’s complaints in a timely manner. The practice offered apologies to people, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care.

We found safe systems of care, in which safety was managed and monitored. For example, there was a system for processing information relating to new people including the summarising of new clinical records and a documented approach to the management of test results. There were systems in place for referrals to appropriate services, which was managed in a timely way.

There were policies and processes in place to keep people safe and safeguarded from abuse. The practice had a safeguarding lead for adults and children and all staff had completed the relevant safeguarding training for their role. The practice held a safeguarding register and clinical records we reviewed showed that they had been appropriately coded where safeguarding concerns had been identified. Clinical system alerts were used to identify people who were at risk of harm or abuse. There were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments. Safeguarding meetings were held on a regular basis to review people at risk. In addition, the practice attended multi-disciplinary meetings as part of the primary care network (PCN) to review vulnerable patients. There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

We found that processes had been strengthened to manage risks and these were being regularly reviewed. For example, there were registers to manage people prescribed high risk medicines. There were processes in place to ensure the practice prioritised care for their most clinically vulnerable people and people were told when they needed to seek further help and what to do if their condition deteriorated. There were systems in place to support people who face communication barriers to access treatment (including those who might be digitally excluded).

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. Risk assessments were in place to identify potential risks and we saw evidence to demonstrate that actions identified had been actioned to mitigate risk. The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested.

A recruitment policy was in place which included how the practice processed personal data in accordance with the General Data Protection Regulations (GDPR). We reviewed 4 personnel files and found appropriate checks such as previous employment record, proof of identity and clinical staff files had evidence to demonstrate that clinical registration checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. We found staff immunisation status records were in place. We found that processes had been reviewed for supervision and oversight and staff now had access to regular appraisals, clinical supervision and were supported to meet the requirements of professional revalidation. We found the practice had reviewed their processes and could demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses and pharmacists.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury. There was an infection control lead in place and an infection control audit had been carried out in May 2024. The practice had achieved 100%. We found all staff were up to date with training.

Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. There was a system in place to ensure all information including documents, laboratory test results and cytology reports were reviewed and actioned in a timely manner. We found that test results were managed in a timely way and all workflow was followed up and actioned appropriately. Our review of clinical records in relation to the clinical searches identified that care records were managed in line with guidance and legislation. The practice had systems for monitoring two week wait referrals to ensure people were seen and held multidisciplinary meetings with other agencies to share and discuss information relating to care and treatment, for example, those on the practice palliative care register. Further reviews of the clinical registers showed some people required up to date monitoring of their health conditions. The findings of the clinical searches were discussed with the clinical team and following the assessment we were provided with evidence to demonstrate that action had been taken to review people identified through the clinical searches. We found that the practice had taken action to review safety alerts to ensure that these were being followed appropriately to ensure people were protected from harm.