The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Avtar Suri Also known as Dr AS Suri

Overall: Good read more about inspection ratings

Birchills Health Centre, 23-37 Old Birchills, Walsall, West Midlands, WS2 8QH (01922) 614896

Provided and run by:
Dr Avtar Suri

Important: The provider of this service changed. See new profile

All Inspections

12 December 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Avtar Suri on 10 November 2016. The overall rating for the practice was good with requires improvement for providing safe services. We found two breaches of legal requirement and as a result we issued two requirement notices in relation to:

  • Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Good Governance
  • Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Staffing

The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Avtar Suri on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 12 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 10 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The safe key question is now rated as good and overall the practice remains rated as good.

Our key findings were as follows:

  • The practice had improved their recruitment procedures. The relevant information was recorded in the two staff files reviewed.
  • The immunisation status of all staff for Hepatitis B had been established and recorded on a spreadsheet.
  • All staff who acted as chaperones were trained in the role and had Disclosure and Barring Service (DBS) checks completed.
  • The practice had invested in an on-line training system for staff.Clinical and non-clinical staff had completed infection control training.
  • The practice had reviewed the system in place for recording and acting on significant events and incidents. Five significant events had been recorded during 2017. We saw that these had been acted on appropriately and lessons learnt shared with staff.
  • The practice had introduced a log to record all alerts received. The alerts were shared with the clinicians, who signed the log to say they had received and acted upon the alerts. However, the log did not record the action taken as a result of the alert.
  • We noted during our previous inspection that the practice had lower than average results for the national screening programmes and childhood vaccination programme. The practice was aware of the low results for the national screening programmes and had taken action to improve these. A member of reception staff had been trained to follow up patients who did not take part in the screening programmes.
  • The practice was part of a local initiative to encourage participation in the bowel screening programme. This initiative involved following up patients who failed to respond or responded inappropriately to the screening kit. The practice identified these patients on a monthly basis, contacted them, encouraged participation and ordered a new screening kit if required.
  • The practice’s uptake for the cervical screening programme was 79% (up from 78%), which was close to the 80% coverage target for the national screening programme. Staff told us they were committed to proactive opportunistic targeting and used the alerts on the electronic records to remind reception staff to encourage patients to book appointments for the screening programmes. The practice had introduced a text message service for patients who did not attend their appointment or who were overdue. The service included an option to text back and so far, three patients had replied to the text message.
  • The practice manager told us they were being supported by the breast screening team to encourage participation in the national breast screening programme. The screening team were going to send letters out on behalf of the practice to patients who failed to attend their first appointment. The practice also used the text messaging service for patients who did not attend their breast screening appointment.
  • Posters informing patients about breast screening and when the mobile scanning unit was next due in the area were on display in the waiting room.
  • Childhood immunisations were carried out in line with the national childhood vaccination programme. The practice had improved their uptake rates for the vaccines given and these were in line with the target percentage of 90% or above. The immunisation rates for two year olds ranged from 97% to 99%. The practice manager told us that the new patient registration form specifically asked for information regarding childhood immunisations given in other countries. The practice also asked for evidence to support what vaccines had been given.

However, there were also areas of practice where the provider needs to make improvements. The provider should: ion the provider should:

  • Record the action taken as a result of the safety or medicine alerts.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Avtar Suri in Birchills Medical Centre on 10 November 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. The practice recorded and analysed all complaints as significant events and investigated these appropriately. However, the practice did not demonstrate they had a proactive approach to recognising and reporting incidents and significant events other than those identified via complaints.
  • Arrangements were in place to safeguard children and vulnerable adults from abuse, and local requirements and policies were accessible to all staff. Non clinical staff had not received safeguarding training for vulnerable adults; however they were aware of the procedures to follow if they had any concerns.
  • Non clinical staff were not up to date with the latest infection control guidance and training relevant to their role.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Some governance and risk management arrangements were in place, but no risk assessments had been completed in the absence of disclosure and barring checks (DBS) for members of the reception team who occasionally chaperoned. Since the inspection we have received completed risk assessments for staff carrying out this role and the practice informed us that DBS checks are also being sought for staff who carry out the role of chaperoning.
  • Non clinical staff immunisation status was not recorded and no risk assessments had been completed to identify duties, risks and actions to minimise the risk to staff.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour.

However there were areas of practice where the provider must make improvements:

  • Ensure effective recording is in place for checking staff immunisation status and risk assessments have been undertaken in the absence of staff immunisation status to identify duties, risks and actions to minimise the risk to staff.
  • Ensure the infection control action plan is acted on and staff receive the appropriate training relevant to their role.
  • Ensure all staff are risk assessed in the absence of a Disclosure and Barring Service (DBS) check when carrying out chaperoning duties, including assessing risk in relation to staff to ensure understanding and competency when undertaking chaperone duties.

There were also areas of practice where the provider should make improvements:

  • Review recruitment procedures and follow practice policy guidelines to ensure personnel files hold the relevant checks.
  • Ensure staff have the necessary skills, knowledge and competencies to carry out their role.
  • Encourage patients to attend screening and immunisations.
  • Review current process for recording of significant events and incidents other than those identified via complaints.
  • Review current process for the actioning of safety alerts in the absence of the practice support pharmacist.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24 July 2013

During a routine inspection

We visited the surgery to establish that the needs of people using the service were being met. On the day of the inspection we spoke with five staff members, two GPs and the practice manager. We also spoke with six patients and three children who were accompanying their parent to an appointment. The people we spoke with were generally complimentary about the service.

Patients told us that generally appointments were available at a time convenient to them. Patients were able to book an appointment with a specific GP if they wished. They told us that generally their care and treatment was explained and in most instances they had been happy with the outcome of the consultation.

The staff we spoke with said they had received training appropriate to their role. This had included protecting vulnerable adults and children.

The practice manager had systems in place to monitor the quality of the service provided at the surgery. This included a patient satisfaction survey and a complaints process