Brandon Surgery Dr R Kapur Also known as Belgrave Health Centre

We carried out an announced comprehensive inspection at Brandon Surgery Dr R Kapur, on 18 June 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and for safe and well-led.

• Nursing staff did not receive adequate non-patient facing time to complete training and development.
• The significant events process was not understood by all staff. Not all staff were included in the process which limited the opportunities for learning and prevention of future incidents.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Staff worked together and with other agencies.
• Staff we spoke with confirmed there was an open culture, and senior staff were very approachable.
• Recruitment checks were not carried out in accordance with regulations as a full employment history and DBS checks prior to employment were not requested.

We have rated this practice as good for effective, caring and responsive and for all population groups.

We found that:

• Patients we spoke with and comment cards we reviewed told us staff treated patients with kindness and respect and involved them in decisions about their care. Patients were complimentary about the practice staff and especially the reception team.
• There was an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines, with appropriate monitoring and clinical review prior to prescribing.
• Patients’ treatment was regularly reviewed and updated. Patients with long term conditions received an annual review and patients were visited at home when necessary.
• Patients who did not speak English or for whom English was not their first language, were called by members of the practice team who spoke the same language, to ensure appointments were not missed or they understood what was required of them.
• The practice organised interpreters to be present at nurse clinics and nurses provided diagrams so patients better understood the procedure and treatment.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  

The areas where the provider should make improvements are:

• Review carer numbers to ensure all carers are identified

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care