16 November 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
This practice is rated as Good. (Previous inspection September 2016 – Good)
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The concerns raised in Safe and Well Led affect all of the population groups.
The population groups are rated as:
Older People – Requires improvement
People with long-term conditions – Requires improvement
Families, children and young people – Requires improvement
Working age people (including those retired and students – Requires improvement
People whose circumstances may make them vulnerable – Requires improvement
People experiencing poor mental health (including people with dementia) – Requires improvement
We carried out an announced comprehensive inspection at Dr KP Kashyap’s Practice on 16 November 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
At this inspection we found:
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
- The practice had processes and practices to minimise risks to patient safety but these were not always followed prior to the prescribing of some high risk medication.
- Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
- Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients we spoke with 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. Examples we reviewed showed the practice complied with these requirements.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
The areas where the provider should make improvements are:
- Carry out regular fire drills.
- Consider implementing DBS checks which are role specific, or risk assesments if a DBS check is not considered necessary.
- Ensure that regular locum staff attend clinical meetings and are included in shared learning outcomes.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice