Dr PM Patel/Dr R Kumar Also known as Suttons Avenue Surgery

We carried out an announced comprehensive inspection at Dr PM Patel and Dr R Kumar on 3 May 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• Systems and processes were not in place to keep patients safe. For example; appropriate recruitment checks on staff had not been undertaken prior to their employment; Actions identified to address concerns with infection control practice had not been taken. The practice had not carried out a fire risk assessment, staff had not carried out fire evacuation drills and there were no fire alarms or firefighting equipment and the practice were unaware that the oxygen cylinder was empty.

• There was an open and transparent approach to safety and a system in place for reporting significant events; however learning was not always shared with all relevant members of staff.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Mandatory training had not been carried out by all non-clinical members of staff, this included safeguarding, fire and infection control training and there were inconsistencies in how training records were kept.
• Non-clinical staff had not completed an appraisal or personal development plan since 2013.
• There was no evidence of the patient participation group meeting since March 2015 and the practice could not demonstrate changes that have been made to the practice as a result of the patient participation group.
• 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 easy to make an appointment with a named GP and 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure equipment used in the treatment used for emergencies are available and in date.

• Ensure recruitment arrangements include all necessary employment checks for all staff, for example DBS checks or risk assessments and references.

• Mitigate risks associated with fire, infection control.

• Provide staff with appropriate training, policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

• Put systems in place to ensure mandatory training is carried out by all members of staff.

The areas where the provider should make improvement are:

• Ensure learning and outcomes from significant events, incidents and complaints are shared with all relevant members of the practice.

• Review arrangements for the patient participation group that would allow for regular meetings and patient input into the services provided.

Letter from the Chief Inspector of General Practice

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice