9 September 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Rao on 9 September. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
- Staff understood there was a process to follow to raise concerns, and to report incidents and near misses. However this was not implemented fully within the practice as incidents were not always identified.
- Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and infection control training.
- Data showed patient outcomes were at or above average for the locality. Audits had been carried out in order to improve patient outcomes.
- Patients said they were treated with kindness, 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.
- Urgent appointments were usually available on the day they were requested.
- The practice had a number of policies and procedures to govern activity, but staff did not know what they were and how to access them.
- Non-clinical staff including the practice manager had not received any appraisals.
The areas where the provider must make improvements are:
- Ensure recruitment arrangements include all necessary employment checks for all staff. This includes making sure all nursing staff have a criminal records check through the Disclosure and Barring Service (DBS). Where non-clinical staff perform chaperone duties, the practice must risk assess and record whether a DBS check is required.
In addition the provider should:
- Ensure lessons learned from significant events, incidents and accidents are shared with practice staff.
- Ensure all staff have received training appropriate to their role, for example, infection control and chaperone training.
- Ensure that all staff are supported by receiving appraisals.
- Carry out regular fire drills to ensure staff know what to do in the event of a fire.
- Keep cleaning records to demonstrate adequate levels of cleanliness are maintained.
- Ensure all staff know how to access policies, procedures and guidance to carry out their role.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice