Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr PL Gupta's Practice on 31 March 2016. While the overall rating for the practice was good, the practice was rated as requires improvement for Safety. The full comprehensive report on the 31 March 2016 inspection can be found by selecting the ‘all reports’ link for Dr PL Gupta's Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 February 2017. The inspection was carried out to check that the provider had met the legal requirements we set out following the March 2016 visit. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

• The provider had put in place suitable guidance, policies and procedures available to staff for the protection of vulnerable people.

• The records made of the reporting of significant events were improved to ensure fuller detail was captured and the learning opportunity for staff was promoted.

• Infection control risk assessments had been introduced.

• Staff files had been reviewed and updated information had been added to show the full and completed training undertaken for each staff member. However, one of the files we viewed did not show a DBS for a new reception staff member who had been recruited since the last inspection. Confirmation was received after the inspection that a new DBS had been applied for this member of staff.

• The practice had purchased oxygen equipment on site for use in an emergency situation.

As a result of the actions taken the practice is now rated as ‘good’ for providing a safe service.

We also found that the provider had made a number of improvements to the service in response to recommendations we made at our last inspection. These included;

• At our inspection on the 31 March 2016 we said the provider should review the system in place for complaints to ensure a full record of the complaint was logged in line with the practice policy. At the inspection undertaken on the 22 February 2017 we found the practice had revised the system in place for handling complaints and concerns. A complaints policy and procedures were now in place. The practice manager had implemented a new patient’s information sheet for complaints. We looked at complaints received in the last 12 months. We found the records made of the stages the practice had gone through, had improved in terms of written details and a fuller audit trail of steps taken in response to the complaint and the issues raised. The practice manager confirmed that complaints were now discussed at practice meetings and an annual review of complaints was planned.

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 PL Gupta's Practice, known locally as Derby Lane Medical Centre on 31 March 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 a system in place for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, the records made of such events required improvement.

• Systems were in place to deal with medical emergencies and staff were trained in basic life support.

• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Feedback from patients on the day of the inspection about their care was consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Feedback also indicated there were problems with accessing GP appointments but there was good open access to GP appointment each day for urgent and emergency appointments.
• Data showed that outcomes for patients at this practice were similar to outcomes for patients locally and nationally.
• Information about services and how to complain was available but required improvement to be easily understood.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership and staff structure and staff understood their roles and responsibilities.

• The practice provided a range of enhanced services to meet the needs of the local population.

The areas where the provider must make improvements are:

• The provider must ensure that suitable guidance, policies and procedures are available to staff for the protection of vulnerable people.

The areas where the provider should make improvement are:

• The records made of the reporting of significant events required improvement to ensure the full detail of the event is captured and the learning has taken place.

• Infection control risk assessment should be completed on a regular basis and signed off by the registered provider.

• The provider should review the system in place for complaints to ensurea full record of the complaint is logged in line with the practice policy.

• Staff files should have records and certificates to show the full and completed training undertaken for each staff member.

• A risk assessment for the need to have oxygen on site in an emergency should be undertaken. According to current external guidance and national standards this equipment should be in place in all practices.

• All staff practice meetings should be introduced.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice