Devaraja V C & Partner Also known as The Sorrells Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Devaraja V C & Partner on 25 February 2016. The overall rating for the practice was requires improvement. The full comprehensive report for this inspection can be found by selecting the ‘all reports’ link

for Devaraja V C & Partner on our website at www.cqc.org.uk.

We then carried out a desk based focused inspection on 4 October 2016 to confirm that the practice were now meeting the legal requirements in relation to the breaches of regulations that we identified in our previous inspection on 17 December 2015. This report covers our

findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• There was an effective governance system in place to assess and monitor risks and the quality of service provision.
• Practice policies were reviewed and in date.
• There were now systems in place for the medicines management of high risk medicines.
• Oxygen with masks was available on the premises.
• Practice policies and procedures were reviewed and updated.
• There was a clear management structure and staff who had a clinical and management role had updated job descriptions and protected time to reflect this.
• Staff in administrative roles had access to training to ensure they had the appropriate skills to fulfil their role. They were also given dedicated time to complete administrative duties.
• Although audits and re-audits were completed there was little evidence of improvement to patient outcomes in the audit documentation.

However, there was also one area of practice where the provider needs to make improvements.

The provider should:

• Use the findings from completed audits to improve the services for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Devaraja V C & Partner on 25 February 2016. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and managed, but there was limited documentation to support this.
• Data showed patient outcomes were mostly in line with local and national outcomes. Although some audits had been carried out, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes. 
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. Where staff needed to refer to other professionals this was completed in a timely manner.
• All patients said they were treated with compassion, dignity and respect. They told us they were involved in their care and decisions about their treatment.
• Information about services and how to complain was displayed, available in a number of ways and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice was restricted by its premises however staff made arrangements to ensure that they were able to treat all patients and meet their needs.
• The practice had no clear leadership structure and limited formal governance arrangements.
• The practice had a number of policies and procedures to govern activity, but some had several versions which were not version or date controlled.
• The practice sought feedback from staff and patients, which it acted on.
• The provider and staff were aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

• Review systems in place for the medicines management of high risk medicines.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Ensure that oxygen is available on the premises with child and adult masks.

The areas where the provider should make improvement are:

• Review and update procedures and policies.
• Have a clear management structure and accountability with job descriptions that support this.
• Ensure staff in administrative roles have the appropriate skills and training to fulfil their role effectively.
• Carry out re-audits of clinical audits to monitor and demonstrate sustained improvement of patient outcomes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice