Source · CQC inspection

Dilip Sabnis PCT Medical Services (PCTMS) Practice

Provider North Essex Partnership University NHS Foundation Trust Type NHS Healthcare Organisation Region East Last inspected 23 Nov 2016

Overall rating: Inadequate View full CQC report

Domain ratings

Five CQC key questions

Safe

Inadequate

Effective

Inadequate

Caring

Requires Improvement

Responsive

Inadequate

Well-led

Inadequate

Earlier inspection findings

pre-2024 framework · 13 must-do 1 should-do

Must-do actions (13)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 13

Must do

Safe

Ensure staff understand, recognise, record, investigate and identify and learn from significant incidents.

⚠ There was no effective system in place for reporting, recording, investigating, responding and learning from significant events.

Must-do action 2 of 13

Must do

Safe

Establish an effective system to action medicine safety alerts and monitor and prescribe safely in accordance with guidance.

⚠ There was an insufficient system in place to receive or respond to Medicine and Health products Regulatory Agency (MHRA) alerts. Prescribing practices were unsafe and patients receiving high risk medicines had not been appropriately reviewed.

Must-do action 3 of 13

Must do

Safe

Undertake a risk assessment in relation to emergency medicines held at the practice to enable staff to respond to a medical emergency.

⚠ The practice did not hold appropriate emergency medicines for patients allergic to penicillin and who may experience a diabetic hypoglycaemia episode.

Must-do action 4 of 13

Must do

Safe

Follow published guidance in relation to the storage of medicines in fridges.

⚠ Medicines were not being stored appropriately and the cold chain procedure was not being followed. The fridge temperatures had exceeded the recommended storage requirements on six occasions in November 2016.

Must-do action 5 of 13

Must do

Safe

Ensure staff are suitably trained to undertake their roles, for example, receiving training in basic first aid.

⚠ Not all clinical staff had undertaken appropriate emergency life support training. Staff had not received fire safety training.

Must-do action 6 of 13

Must do

Safe

Ensure the appropriate supervision of clinical staff in the administration of vaccinations.

Regulation: Regulation 18 (2) (Staffing)

⚠ The registered person had not ensured appropriate supervision of clinical staff in the administration of vaccinations. Patient group directives had not been appropriately authorised for the administration of immunisations to pregnant women.

Must-do action 7 of 13

Must do

Effective

Maintain accurate records on patients, including coding, completion of care plans and inclusion on risk registers to enable the monitoring of their health.

⚠ We found patients were inappropriately coded for conditions they did not have. Care plans were not in place for all patients on their admission avoidance programme. Patients had not been appropriately identified, placed on risk registers and included in multidisciplinary discussions.

Must-do action 8 of 13

Must do

Well-led

Implement an effective system of governance and clinical oversight to assess, monitor and improve the quality of safety for patients and identify and mitigate risks relating to the health, safety and welfare of patients.

⚠ The overarching governance systems for the practice had not been effectively embedded into the practice. There was a lack of clinical oversight. The practice did not have a clear vision and strategy for delivering primary medical services.

Must-do action 9 of 13

Must do

Responsive

Seek and act on patient feedback.

⚠ The practice was performing below averages in relation to most responses relating to involvement in decisions with the GPs. Systems were not in place to support patients to give feedback. There was little evidence of changes being made in response to the feedback.

Must-do action 10 of 13

Must do

Responsive

Operate an effective and accessible complaints system.

Regulation: Regulation 16 (1)(2) (Receiving and acting on complaints)

⚠ The registered person had not put in place effective and accessible complaints systems. The practice did not have an effective complaints procedure in place. It failed to advise patients of their right to advocacy services to support them making a complaint.

Must-do action 11 of 13

Must do

Effective

Implement a system of quality assurance to include clinical audit.

⚠ The practice had no quality improvement processes in place to identify where they might improve. The practice had no evidence of clinical audit or other quality improvement processes in place to improve and inform quality improvement.

Must-do action 12 of 13

Must do

Safe

Staff undertaking chaperone responsibilities should have disclosure and barring service checks or be risk assessed for the role.

⚠ Staff had received training to undertake chaperone duties but had not received Disclosure and Barring Service (DBS) checks.

Must-do action 13 of 13

Must do

Safe

Ensure the secure storage of blank prescription stationery and record their issue to clinicians.

⚠ The practice failed to record the issue of blank prescription stationery and they were not being stored securely.

Should-do actions (1)

Recommended improvements to enhance service quality.

Should-do action 1 of 1

Should do

Effective

Identify a system for improving the screening rates of bowel cancer.

Location details

CQC ID: RRDY5

Local authority: Thurrock

Region: East

Inspection report

Type: Comprehensive inspection

Date: 23 November 2016

Rating: Inadequate

Actions: 13 must-do 1 should-do

AI-extracted 3 Jun 2026