This practice is rated as Good overall. (Previous inspection May 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Khine Kyaw on 19 April 2018. This inspection was completed as part of our inspection programme and we also followed up on the recommendations made at the previous inspection.

At this inspection we found:

• The improvements required from the inspection in 2015 had been made because staff had completed appropriate safeguarding and mental capacity act training; the recruitment process for employing locum staff had been strengthened; the emergency drugs supplied meet best practice guidance; clinical meetings took place to discuss patient outcomes and share other relevant information between staff and processes had been introduced to share patient safety alerts.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However changes made were not always checked and monitored for ongoing improvement.
• The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice had formal registers for patients who were vulnerable, at risk of safeguarding matters and those whose circumstances made them vulnerable such asylum seekers and patients with a learning disability.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• We received 26 comment cards all of which were very satisfied with care and treatment provided by all staff at the practice.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• 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.
• Staff worked well together as a team, knew their patients well and all felt supported to carry out their roles.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
• The practice had a well-established and active Patient Participation Group (PPG) who worked closely with staff to monitor and develop services.

The areas where the provider should make improvements are:

Review how well staff are prepared for medical emergencies.

Review the safety checks completed for emergency equipment held centrally at the health centre.

Review the system for storing prescriptions when the surgery is closed.

Review the staff performance management protocol to include locum staff.

Review job descriptions.

Review system to follow-up children who do not attend GP appointments booked by their guardians.

Review the system for analyzing complaints and incidents so that overall trends are identified long-term improvements monitored.

Review the system for following up children if their parents or guardians make them a routine appointment and then fails to bring the child to the surgery.

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 Khine Kyaw, known as Cedar Cross Medical Centre on 24 February 2015. Overall the practice is rated as good for effectiveness, caring, responsive and well led. We found it required improvement for aspects of safety.

Our key findings 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.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and considered 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.
• Information about services and how to make a complaint was available 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 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should

• Ensure all staff undertake adult safeguarding and Mental Capacity Act 2005 training
• Ensure doctors have available emergency drugs or have in place a risk assessment to support their decision not to have these available for use in a patient’s home.
• Ensure effective arrangements are in place for the recruitment of locum GPs.
• Consider the use of clinical staff meetings to provide support to Clinical Staff and to share experiences such as patient safety incidents with clinical staff to avoid reoccurrence.
• Review the process in place for sharing national patient safety alerts.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice