Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr BK Jaiswal’s Practice and on 28 February 2016. The overall rating for the practice was good. The full comprehensive report on 28 February 2016 inspection can be found by selecting the ‘all reports’ link for Dr BK Jaiswal’s Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 13 March 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 on 28 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At our previous inspection on 28 February 2016, we rated the practice as requires improvement for providing safe services. Not all staff were had received mandatory training and the practice had not risk assessed not having a defibrillator. In addition, the practice did not provide us with evidence to demonstrate that medical equipment had been calibrated and annual internal infection control audits were carried out. At this inspection we found these issues had been satisfactorily addressed with the exception of infection control training and fire safety. However, we saw evidence that both these training had been booked. The practice is now rated as good for providing safe services.

Our key findings were as follows:

• The practice had a defibrillator available on the premises with adult and children’s pads and we saw records to confirm this had been checked daily.

• The practice provided us with evidence which demonstrated that all medical equipment had been calibrated by an external organisation.

• Annual internal infection control audits were implemented.

• We found that not all staff had completed mandatory training, for example, fire safety and infection control. However we saw evidence which confirmed this training had been booked for April 2017.

• Following the comprehensive inspection, the practice told us they took practical steps to ensure all patients had the opportunity to join the patient participation group (PPG).The PPG was brought to patient’s attention by way of the practice leaflet, repeat prescriptions and staff members who informed patients about it opportunistically.

• Policies we reviewed were all updated and practice specific. All practice policies were digitised, however they also had access to paper copies which were kept in a clearly labelled folder in a lockable room.

The area where the provider should make improvement is:

• Ensure mandatory training is completed timely and develop a more rigorous recording system to highlight training nearing expiration.

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 Dr BK Jaiswal’s Practice on 28th January 2016. Overall the practice is rated as good.

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.

• Some risks to patients were assessed and well managed. However, systems and processes to address risks were not implemented well enough to ensure patients and staff were kept safe.

• The practice had a number of policies and procedures to govern activity.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However not all staff had up to date skills, knowledge and experience to deliver effective care and treatment.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand.

• Patients said they found it difficult to make an appointment with a named GP as there was one GP partner and two locum GPs and therefore lacked continuity of care. However urgent appointments were 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 and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

• Ensure that all mandatory training is completed according to the recommended schedule.

• Ensure that a risk assessment is carried out for not having a defibrillator on the premises.

• Ensure that calibration tests are carried out annually for all medical equipment

• Ensure infection control audits are carried out annually by trained staff.

The areas where the provider should make improvements are:

• Review the make-up of the Patient Participation Group to be a true representation of the patient population of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice