- GP practice
Archived: Dr P Pal and Jemahl
Important:
This service is now registered at a different address - see new profile
All Inspections
19 April 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr P Pal and Jemahl on 19 April 2016. The overall rating for the practice was Good. However, for providing safe service the practice was rated as requires improvement. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Dr P Pal and Jemahl on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 19 April 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. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection on the 19 April 2016.
Overall the practice is rated as Good.
Our key findings were as follows:
- During our previous inspection in April 2016 we saw that the practice had considered the risks associated with not undertaking Disclosure and Barring Service (DBS) checks for some staff. However, these risk assessments were not effective to mitigate all risks. During this inspection we saw that all staff had undergone a DBS check.
- When we inspected the practice in April 2016, we saw that the practice had carried out an annual analysis of significant events. However, all recorded incidents and significant events were not included in the analysis. During this follow up inspection, the practice had carried out an annual significant event audit including all significant events and occurrences.
- At our previous inspection we saw evidence that patient medicine safety alerts were received and cascaded to relevant staff. However, the practice could not evidence the actions taken following receipt of safety alerts. During this follow up inspection the practice could demonstrate that a process was in place for the monitoring of actions taken following the receipt of medicine safety alerts.
- When we inspected the practice in April 2016 we saw that health and safety risk assessments were not in place. At this follow up inspection we noted that actions had been taken to manage and mitigate risks related to health and safety.
- During our previous inspection in April 2016 we saw the practice had a whistle blowing policy which needed review as it did not reflect existing guidance. During this follow up inspection we saw that the policy had been reviewed and staff members we spoke with were aware of the changes.
- Treatment protocols clearly set out what actions should be taken in response to the results of health assessments, explaining the reason and justification for each action for health care staff. When we inspected the practice in April 2016, we saw the practice did not have protocols for the nurse and the healthcare assistant to guide decision-making around specific health issues. For example, the frequency of a structured review for an asthma patient. During this follow up inspection we saw that treatment protocols were available for staff on the practices computer system and they were based on the National Institute for Health and Care Excellence (NICE) guidance. They included protocols on Hypertension, Asthma, and Angina amongst others.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
19 April 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr P Pal and Jemahl on 19 April 2016. Overall the practice is rated as good.
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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
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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. Information about services and how to complain was available and easy to understand.
- 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 areas where the provider must make improvement are:
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Appropriate risk assessments must be in place to assess and mitigate risks in the absence of DBS checks to ensure safety and welfare of service users.
The areas where the provider should make improvement are:
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Review incident reporting process to ensure it is consistent and facilitates effective analysis.
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Actions taken following medical alerts should be documented and audited
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Review the practice whistleblowing policy to include third party details and ensure all staff are aware of process.
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Ensure that risk is assessed and managed in relation to safety of the premises.
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Ensure appropriate treatment protocols are available for staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice