Dr Uday Kanitkar Also known as Moss Side Medical Centre

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

The system for recording and acting on significant events had been reviewed and was effective. We detected potential risks in the environment around the safety of clinical equipment. Appraisals had been repeated for staff to ensure they were meaningful. Training was up to date. The process for authorising nurses and healthcare assistants to administer vaccinations had been reviewed and was effective. Prescription security had been reviewed and was effective. This key question has been rated as requires improvement.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The assessment of 17 May to 6 June 2024 found that although staff told us they knew how to describe significant events and leaders told us they were regularly discussed, this was not always the case.

At this assessment the Registered Manager and business manager told us a new system had been put in place. Significant events were recorded and could be seen by all staff. They were routinely discussed in meetings, so staff were involved in shared learning.

The practice had put a new significant event policy in place. This clearly outlined the updated process the practice should follow. The practice provided us with their significant events log which showed there had been 7 significant events since our previous assessment, all dealt with under the new process. We were able to view the documentation for these and we saw incidents were clearly recorded along with any actions required. We saw that significant events were routinely discussed in meetings with all appropriate staff, and a record of the discussion was clearly recorded.

We therefore had assurance that safety was a top priority, that significant events were appropriately investigated and reported, and lessons were learned to improve care for others.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The assessment of 17 May to 6 June 2024 found that risk assessments had not been accurately carried out, the monitoring of issues previously identified was not adequate, and items of out of date or potentially unsafe equipment was found in clinical rooms throughout the practice. At this assessment we found improvement in all these areas.

The Registered Manager and business manager described how they had updated their policies and procedures following our previous assessment, and risk assessments had been revisited to ensure their accuracy. They told us that some items previously found to be potentially unsafe had actually not been clearly recorded. They said they had gone through all the equipment on the premises and ensure safety tests were repeated where appropriate.

Our observations on this assessment found that all environmental issues previously identified as needing improvement had been actioned. An unsafe oxygen cylinder had been removed. We checked all the consultation rooms, and all equipment had been appropriately calibrated with the required portable electrical testing carried out.

The business manager had oversight of all processes relating to environmental safety. An operations manager had recently been appointed for the practice, and they would also have responsibility for environmental checks. Processes were in place to ensure regular accurate environmental checks took place and these were shared with leaders and other staff. Policies had been updated, with the business manager and partners ensuring they were fit for purpose and accurate. The managers and partners had a system in place to continue to monitor improvements that had been identified as necessary following our previous assessment, and we saw this system was accurate and evidenced continued improvement.

We therefore had assurance that safety of the environment was a priority and had improved since our previous assessment.

The assessment of 17 May to 6 June 2024 found supervision was in place for the healthcare assistant but this was not adequately recorded. Induction for new staff took place but was not role specific. Evidence of staff training was not readily available, and appraisals were not appropriately carried out or recorded. At this assessment we found improvement in all these areas.

The Registered Manager and business manager told us how they had reviewed all their processes relating to staffing, and policies had been reviewed. Where they felt it was appropriate staff appraisals had been repeated to ensure they were meaningful. Staff had been informed what training was outstanding and they were given time to catch up on this.

We saw evidence that a new role specific induction process had been put in place so all new staff, knew what training and awareness was needed during the first 6 months of their employment. Regular probation meetings with their manager were recorded and the staff members and managers both had to sign when specific parts of the induction process had been completed.

A GP partner had regular meetings with the healthcare assistant, and these were documented. This was to discuss both clinical and non-clinical aspects of their work.

We saw that staff training was appropriately recorded and available for us to see. This was now up to date. Staff had protected time to complete their training.

A new process for appraisals had been put in place. Previously not all appraisals had been fit for purpose and where the business manager had identified this a new appraisal had taken place. Clear records were kept of all appraisals, with identified learning and career progression also documented.

We therefore had assurance that safe and effective staffing was a priority, improvements had been made, and processes were in place to ensure continuous improvement.

The assessment of 17 May to 6 June 2024 found infection prevention and control (IPC) audits were not adequately completed or accurate, out of date clinical items were in several consultation rooms, and policies did not contain full information and were not followed. At this assessment we found improvement in all these areas.

The business manager told us a nurse associate had recently started work at the practice. They would be taking the lead for IPC, and they had support from the healthcare assistant. They had joined an IPC champion group in the locality so help with support and keeping up to date with best practice. The business manager and Registered Manager told us they had updated policies and procedures to ensure all regular checks were carried out to a high standard.

We checked all the rooms in the practice. We saw that all areas of the practice were clean and free from dust and clutter. Cleaning schedules were in place, and the cleaning company carried out regular checks.

We checked all the consultation rooms and did not find any out of date items. Privacy curtains had been changed in line with policies and sharps disposal units were not over-filled, were correctly labelled, and were changed at appropriate intervals.

The IPC policy had been updated so all information was accurate. The practice was in the process of confirming who the infection prevention and control lead for the Integrated Care Board (ICB) was, so this information had not yet been included in the policy. We saw evidence that the policy was being followed. The practice had ensured all staff had up to date training at the correct level, and waste management training had also been completed.

The IPC lead carried out an annual audit of all aspects of IPC, and a documented monthly walk-through of the practice also took place.

We therefore had assurance that infection prevention and control was a priority, improvements had been made, and processes were in place to ensure continuous improvement.

The assessment of 17 May to 6 June 2024 found Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were not correctly completed, meaning that nurses and the healthcare assistant were not correctly authorised to administer vaccinations. Risk assessments were not in place for emergency medicines not stocked by the practice. Prescriptions were not securely managed or stored, and not all medicine reviews were appropriately documented. At this assessment we found improvement in these areas.

The Registered Manager and business manager told us they had reviewed all their processes following the previous assessment and the monitored the actions identified as being required to ensure improvements had been made and were embedded into the practice.

We saw that medicines were stored safely and securely with access restricted to authorised staff. There was an effective system in place to check stock levels and expiry dates. The practice did not hold all the recommended emergency medicines, but we saw the need for these medicines had been risk assessed and evidence of this was seen.

The process for managing PGDs had been updated and the use of PGDs was included in the documented nurse induction. We saw that PGDs were well organised and correctly signed. The process for managing PSDs had also been updated. A new form was in use that was signed by a GP partner and the nurse associate or healthcare assistant, giving authorisation for medicines to be administered appropriately. These were then scanned onto the patient notes.

All processes around medicines optimisation had been reviewed following previous inspections and assessments and regular checks on these processes were carried out by GP partners and the business manager.

The Prescription Security Policy had been updated and completely revised. The process was clear and had been simplified. Blank prescriptions were now never kept in consultation rooms, and all prescriptions were signed for and documented. The process was audited every month to ensure all prescriptions were accounted for.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. We saw evidence that the improvements previously made had been sustained. Where any monitoring was not up to date, we saw the Registered Manager had taken immediate action. We saw that a medicine review had no linked consultation. The Registered Manager provided evidence that this had been discussed during a clinical meeting and all GPs were reminded to document their medicine reviews fully.

We therefore had assurance that medicine optimisation processes were priorities, and processes were in place to ensure continuous improvement.