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 was not effective. We detected potential risks in the environment around the safety of clinical equipment. Appraisal for non-clinical staff was not a priority. Some training identified as essential had not been carried out. The process for authorising nurses and healthcare assistants to administer vaccinations was not effective. Prescription security was not effective.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The inspection of 30 and 31 August 2023 found there was no effective system for managing significant events (SEAs). The provider told us no minutes were taken for meetings where SEAs were discussed, and they were unable to provide us with evidence SEAs had been investigated. At this assessment, staff told us they knew how to report significant events and leaders told us all incidents were discussed at practice meetings. We sent a staff feedback form to staff, and 6 of them returned it to us. We asked them to describe an SEA where learning had been shared with them. Only 2 staff responded to the question, and they described an SEA that was not included in any documentation (SEA logs, SEA forms and meeting minutes) supplied to us by the practice.

The practice provided us with a document titled ‘Significant Event Audit Policy’. This was not dated and there was no indication of who wrote or authorised it, what version it was or when it was to be reviewed. The policy stated an SEA form would be completed for each event and this would then be put on the agenda to discuss at the next practice meeting. The practice provided us with their significant events log which showed there had been 8 significant events since our previous inspection. We asked for the forms relating to these SEAs. The practice was only able to provide forms for 4 SEAs in total, and only 2 of these were from the period since the last inspection. The meeting minutes for 27 February 2024 refer to an SEA. This did not relate to any SEA on the log, and no form was available for this. GPs described an SEA from April 2024. This was not on the SEA log and no form was available for this. It was recorded on the SEA log that an SEA from March 2024 would be discussed in the May 2024 meeting. The minutes for the practice meeting on 21 May 2024 did not document a discussion about the SEA. We therefore did not have assurance that safety was a top priority, that SEAs were appropriately investigated and reported, or that lessons were learned to improve care for others.

The inspection of 30 and 31 August 2023 found large quantities of physical patient records waiting to be summarised were not held securely. Patient names and details were also in a clinical room. At this assessment we saw a reduction in the number of records waiting to be summarised. Those that had not yet been summarised were kept securely in a locked office only accessible through another locked door. The provider had recruited a new staff member with summarising as 1 of their main duties. We went into all clinical rooms and did not see any patient identifiable information in any room.

The inspection of 30 and 31 August 2023 found several areas of concern around the safety of the environment. Rooms were cluttered, some items such as clinical waste bins and examination couches were poorly maintained, window blinds were in a poor state of repair, with the loops and chains posing a ligature risk, and environmental audits were not available. At this assessment the business manager told us a member of the administration team now had responsibility for carrying out premises and health and safety risk assessments, but they were unsure when they had been carried out. They provided us with a document titled ‘working doc cqc march 2024’ which stated, “We are working towards re auditing the room inspection audit following our changes we have made in house and agree that the audit was not actioned effectively”, which referred to the audit provided at the August 2023 inspection. This document also stated they had carried out the required maintenance at the practice.

Our observations on this assessment found environmental improvements had been made. Clutter had been removed from all rooms, replacement blinds with safety cords were at all windows and items such as examination couches, lamps and clinical waste bins had been repaired or replaced. However, in room 6 there was a large oxygen cylinder free-standing on the floor. This had an expiry date of 13 April 2013. We brought this to the attention of the Registered Manager who stated they were unaware it was there. In 4 rooms we found equipment such as pulse oximeters, scales and blood pressure monitors should have been re-calibrated by 21 April 2024, but they had been missed. We saw other equipment had been re-calibrated on 15 April 2024.

The Registered Manager and infection control lead told us staff took all equipment which needed to be re-calibrated into the treatment room to be checked, and the equipment which had not been checked must have not been taken to the room. They told us they did not have an inventory of equipment so had not realised any items had not undergone re-calibration. Although we saw there were regular checks of the in-date oxygen kept in room 1, the oxygen cylinder in room 6 was not included in those checks. The practice provided us with their Fire Safety Policy. This was not dated and there was no indication of who wrote or authorised it or what version it was. It had a review date of 1 August 2024. The practice provided us with their most recent fire risk assessment, which had been completed on 29 May 2024, the day prior to our assessment. This stated that the oxygen cylinder was safely stored in room 1, and oxygen was kept in a locked room. It stated that all items of portable electrical equipment had been retested on 24 May 2024. This was incorrect. The practice provided us with an ‘Internal Inspection of Premises Checklist’ that had been completed on 29 May 2024. This did not show that each room in the building had been checked. Instead, it had headings such as ‘temperature’, ‘lighting’ and ‘safety’. The heading of safety stipulated “The workplace and certain equipment, devices and systems should be maintained and in efficient working order”. The comment on the checklist was “Risk assessment undertaken due for review”. No other health and safety risk assessment was provided by the practice.

The inspection of 30 and 31 August 2023 found several concerns around safe and effective staffing. Clinical supervision did not take place and there was no formal assessment of the competence of clinical staff, including trainees. Induction records were only kept for reception, not clinical staff, and staff, including clinical staff, were not up to date with their training. At this assessment the Registered Manager told us they had set up a weekly supervision meeting for the healthcare assistant, but there was no nurse employed at the practice at that time. The practice no longer used locum GPs, and reviews, including a 6-monthly review, took place for the salaried GPs. The Registered Manager met with trainee GPs after each of their sessions to review service users and they told us they noted this on the service user records. In addition, they told us they carried out documented monthly dip sampling audits, particularly on scanning and coding.

We saw evidence of the dip sampling audits carried out by the Registered Manager on clinical staff. Records were kept and if any issues were identified these were discussed with the relevant clinician, with the discussion documented. Induction records for new staff were now kept by the practice. However, they were not specific to role, so the healthcare assistant and the receptionist induction form was the same. We saw that for a salaried GP there had been a documented 6 month review with the Registered Manager to discuss progress, and a personal development plan was in place. Records kept of the weekly supervision meeting between the Registered Manager and the healthcare assistant were made by the healthcare assistant, not their supervisor. Detailed information was not available. For example, under the topic ‘Abnormal ECG‘ the details recorded were “Advice given” For ‘training’, “Discussed progression” was recorded. For the topic ‘home visits’ it was recorded “Covid injections”. Evidence of training for all staff, clinical and non-clinical, was not readily available and there was no system in place to monitor training for all staff. We saw that the majority of mandatory training had been completed, but for 1 GP and the business manager it was recorded as having been completed on the day the practice provided us with the information. The business manager told us the date on the records was incorrect. Appraisals for administrative staff had taken place during the month prior to our assessment. The business manager had documented these on pre-appraisal forms designed to help the appraisee prepare for their performance appraisal. They were not signed by the appraiser or the appraisee and some did not contain the full date of the appraisal. They did not include an assessment of competence, information on objectives, and there was no personal development plan for any staff member. The process was not in line with the Appraisal Policy dated January 2024.

The inspection of 30 and 31 August 2023 found several concerns around infection prevention and control (IPC). There was dirt and dust on surfaces and in sinks in clinical rooms. Rooms were cluttered and so could not be effectively cleaned. Urgent actions required following a waste management audit in May 2023 had not been actioned. Regular infection control and environmental audits were not carried out. Several out of date clinical items were found in clinical rooms. At this assessment, the business manager told us that the healthcare assistant, who started work at the practice in March 2024, was the IPC lead. Their duties included fridge checks, stock control, infection control audits and cleanliness checks and waste management. They told us the most recent IPC audit was carried out in April 2024. The business manager sent us a document titled ‘working doc cqc march 2024’. This stated they had taken action following the previous inspection, and a deep clean of the premises had been carried out. In addition, they had conducted an audit to identify any expired items and taken action to remove and replace these as necessary. They would carry out ongoing quality assurance procedures to prevent recurrence. We did not find this information to be accurate.

We saw that all areas of the practice were clean and free from dust and clutter. Cleaning schedules were in place, and we saw the cleaning company carried out regular checks. We checked all 8 clinical rooms and found out of date clinical items in 3 of them. There were 45 out of date items, including forceps, blood collection tubes, scissors, pre-injection swabs and suture removal packs. In addition to these 45 items, we found 2 packs of out of date glucose test strips and boxes of out of date plasters, gloves, and face masks past their expiry date. Some of the expiry dates were from before the previous inspection. For example, a pair of forceps had an expiry date of 21 December 2020, a pack of glucose test strips had an expiry date of 28 February 2022, and a box of plasters had an expiry date of 10 August 2022. Out of date sterile items pose a risk to service users as their sterility and safe use cannot be guaranteed beyond their expiry date. A disposable privacy curtain in a clinical room had last been changed 1 April 2023. The practice policy was to change them every year. We saw that labels on 3 sharps disposal units had not been completed so it was not known how long they had been in use. In 1 room the sharps disposal unit had been dated 1 May 2023, so had been in use for over a year. Another sharps disposal unit was dated 5 April 2024. Sharps disposal units should be changed monthly.

The IPC policy was not dated or authorised. It had a review date of July 2024. The IPC lead was named as a previous staff member, although the current lead was named elsewhere in the policy. There were gaps in the policy where it had not been fully personalised to the practice. The policy was not being followed. For example, it stated that sharps disposal units should be disposed of 1 month after the date of assembly, and disposable privacy curtains should be changed every year. The policy did not contain information about how to contact the local IPC specialist team. A waste management audit had been last carried out in May 2023. Some areas of concern, such as waste transfer notices, had been addressed. However, the audit highlighted that some sharps disposal units were not labelled correctly, and this had not been rectified. The audit also identified that staff were not trained in waste management, and it stated this should be put in place within 2 weeks. The practice’s ’working doc cqc march 24’ stated “We are committed to ensuring that all staff members are fully aware of and trained in safe waste management practices”. Only 2 staff had received training. The practice supplied us with their most recent IPC audit report, completed in March 2024 by the healthcare assistant who was the IPC lead. The lead had IPC tier 1 training, not the required tier 2 training. There were some gaps where the audit had not been completed. The audit stated there was a disposal unit for the discarding of waste water in the domestic room. The domestic room was the staff kitchen, where all cleaning equipment including mops and buckets were stored. The kitchen sink was the only disposal unit. Sharps disposal units had been checked as part of the audit but the unit in use since May 2023 had not been identified. The business manager told us the hand wash audit was in the IPC audit. However, there was no mention of hand washing in that audit.

The inspection of 30 and 31 August 2023 found several concerns around medicines optimisation. Patients prescribed high risk medicines did not always have appropriate reviews, Patient Group Directions (PGDs) were not correctly authorised, and blank prescriptions were not held securely. There was no monitoring of prescription serial numbers, and they were kept in printers in unlocked rooms. At this assessment the GPs told us they had reflected on the previous findings and made improvements, putting systems and processes in place to ensure good quality of care. The practice provided us with a document titled ‘working doc cqc march 24’. This stated they had reviewed their PGD process and included it on the induction of any staff member who would administer vaccines. It stated this would alleviate errors such as when the PGD was not re-signed by a PGD when a nurse was added to it. Prescription security was not mentioned in the document.

The practice ensured 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. We saw the practice did not hold all the recommended emergency medicines, for example diclofenac, midazolam, and naloxone. Risk assessments had not been carried out to determine their necessity. The Registered Manager told us they would put these in place. Vaccines were appropriately stored, monitored, and transported in line with guidance to ensure they remained safe and effective. We examined the PGD file held at the practice. This was disorganised, and out of date PGDs were filed in between current PGDs in no obvious order. PGDs which were found to have been incorrectly signed at the previous inspection were still in the file. The practice did not have a permanent practice nurse, and a named nurse from a neighbouring practice had worked sessions at the practice since 19 February 2024. This nurse was named on some PGDs, but not on others such as the Zostavax PGD, Shingrix PGD, and HPV PGD. The Hep B Renal PGD had not been authorised. The practice had a healthcare assistant who administered vaccinations, who was not in post at the last inspection. Vaccination authorisation was not part of their documented induction. The healthcare assistant provided us with 3 Patient Specific Directions (PSDs). These were proformas with spaces for the patients’ names, dates of birth, the batch number of vaccines and the arm the vaccination was given in. None of the PSDs were dated. They were fully completed by the healthcare assistant, who also added what vaccination had been administered as this was not included on the proforma. A GP did not sign the PGDs until after the vaccinations had been administered, which meant they were administered without authorisation. The GP did not date the forms.

There had been some improvement in the systems and processes in the service. Polices were in place relating to the shared care process, repeat prescribing and the protocol for high risk drug monitoring. However, processes around ensuring clinical staff were correctly authorised to administer medicines, and prescription security, were not effective. The practice had a Prescription Security Policy. This was not dated and there was no indication of who wrote or authorised it, what version it was, or when it should be reviewed. There was also a Prescription Storage Protocol, created on 10 April 2024. The information in the protocol was also included in the policy. The policy detailed how prescriptions were signed out to clinicians. A stock of prescriptions and a ‘daily script transfer log’ was kept in plastic folders labelled Room 1 to Room 8. These were kept in a locked drawer in a locked room. The date, serial numbers of the first and last prescription issued, and the clinician’s name was noted, along with the initials of the staff member who filled or emptied the printer tray. We looked at the system in place for 2 of the rooms. For both of these the prescription serial numbers did not match the numbers recorded on the log. The clinician’s name was not always recorded, and neither were the initials of the staff member filling or emptying the tray. The policy stated, “All prescription forms in printer trays should be removed and locked away when not in use or out of hours”. We found blank prescriptions in an unlocked printer in a clinical room. We checked the audit trail of the blank prescriptions and they had been in the room since 22 April 2024, with no-one realising they had not been returned in accordance with the policy. The log did not say which clinician had use of the prescriptions, or who had filled the printer.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. We found improvement in all the clinical searches since our August 2023 inspection. For example, 1 out of the 12 patients prescribed methotrexate had not been monitored by the practice in the past 12 months, but they had been monitored by secondary care. Of 95 patients with 3 prescriptions for Gabapentinoids in 6 months, 13 had not been reviewed. It was evidence that these patients were difficult to engage with. We saw that 261 medicine reviews had been carried out in the previous 3 months. We looked at 5 in detail and saw evidence of good quality medicine reviews. However, 1 review had no linked consultation. The registered Manager told us they would remind all GPs to document their medicine reviews fully.