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. 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

We conducted this inspection to follow up on compliance actions made following our last inspection on 02 October 2013 when we found concerns with regards to the provider’s management of complaints.

During our inspection on 02 October 2013 we found that there was not an effective complaints system available and that complaints people made were not fully investigated or responded to appropriately.

During our inspection on 30 December 2013 we found that improvements had been made. We saw that there were notices informing people how to make a complaint and there was an up to date information leaflet informing people of the complaints procedure.

We saw that there was an updated complaints procedure in place. We saw that there was a system in place for complaints to be received, handled, investigated and responded to. There were appropriate arrangements in place with regards to complaints.

We saw evidence that before people received any care or treatment they were asked for their consent and the clinicians at the surgery acted in accordance with people’s wishes. One clinician said, “For any procedure, I explain it in a way that the person understands and I ask questions to check their understanding.”

We spoke with nine people about their care and treatment. They all gave positive comments. One person told us, “The staff are extremely well trained, they are knowledgeable about my results and who I may need to be seen by.”

The surgery had taken steps to ensure that the people who used the service were protected from the risks of the spread of infection. We noted that the surgery was clean during our inspection.

We saw that staff were supported and received appropriate professional development. One member of staff said, “You definitely get training if it is relevant to your role.”

We were told by three people that they had been asked for their views about the surgery. One person told us, “I have been included in discussions about what happens at the surgery.” We also saw a comments book in the surgery waiting room. One person had written ‘very pleased with all staff, they really care.'

We spoke with nine people who used the surgery about how to make a complaint. Eight people told us they would not know how to make a complaint. When complaints were made there was no evidence that they were investigated and responded to appropriately.