Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Suganthamala Radhakrishnan on 2 February 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
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Staff understood their responsibilities to raise concerns, and to report incidents and near misses, however, there was no formal process in place for recording such incidents. When there were unintended or unexpected safety incidents, reviews and investigations were undertaken and lessons learned were communicated to support improvement. People did receive a verbal apology.
- Generally risks to patients were assessed and managed, with the exception of those relating to recruitment checks, health and safety and legionella. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.
- Data showed patient outcomes were high compared to the locality and nationally. Audits had been carried out; we saw evidence that audits were driving improvement in performance to improve patient outcomes.
- Patients said they were treated with compassion, dignity and respect. They also felt cared for, supported and listened to.
- Urgent appointments were available on the day they were requested.
- The practice had some processes and procedures to govern activity, however, they lacked basic written policies, for example significant event reporting, complaints handling and safeguarding.
- The practice did not proactively seek written feedback from patients and did not have an active patient participation group.
The areas where the provider must make improvements are:
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Introduce processes for recording and monitoring significant events, incidents and near misses and record safety incidents thoroughly and ensure that these are discussed at team meetings and recorded.
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Ensure that all staff employed has suitable training, including but not limited to safeguarding children, safeguarding vulnerable adults and basic life support.
- Ensure that appropriate risk assessments are available for fire safety, health and safety, hazardous substances, electrical equipment and legionella.
- Ensure that all medication and medical equipment available at the practice is in date, including but not limited to syringes and needles.
- Ensure that the practice’s complaints system is easily accessible to patients.
In addition the provider should:
- Review and update procedures and guidance to support staff in their work.
- Consider GP provisions for gender specific GP requests.
- The practice should take action to proactively identify patients with caring responsibilities.
Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice