25 July 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 B Das on 5 November 2015. The overall rating for the practice was requires improvement and requirement notices were made as improvements were needed in the safety and suitability of the premises and to governance systems. The full comprehensive report on the November 2015 inspection can be found by selecting the ‘all reports’ link for Dr B Das on our website at www.cqc.org.uk.
This inspection was undertaken on 25 July 2017 and was an announced comprehensive inspection.
Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- There were systems in place to reduce risks to patient safety, for example, equipment checks were carried out, there were systems to protect patients from the risks associated with insufficient staffing levels and to prevent the spread of infection.
- Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance.
- Staff felt supported. They had access to training and development opportunities appropriate to their roles.
- Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.
- Services were planned and delivered to take into account the needs of different and diverse patient groups.
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Access to the service was monitored to ensure it met the needs of patients.
- There was a system in place to manage complaints.
- There were systems in place to monitor and improve quality and identify risk.
However, there were areas of practice where the provider needs to make improvements and the provider should:
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Review the system for reviewing significant events and complaints on a regular basis in order to identify themes and trends and learn from these.
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Review the system for documenting action taken in response to patient safety alerts.
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Review policies and procedures for infection prevention and control to ensure a full range of policies are available to govern activity and reduce risks.
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Review the system for cleaning of clinical equipment.
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Consider implementing a quality improvement programme which includes clinical audits being undertaken in response to local and national priorities.
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Consider the development of the patient participation group to actively encourage seeking feedback from this means.
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Continue to identify and support patients who are also carers
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice