This practice is rated as Good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Outstanding
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Dr. Pankaj Mohanlal Thakrar based at the Village Practice on 15 February 2018 as part of our CQC inspection programme.
At this inspection we found:
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it. The practice confirmed appointments were easy to access and routine appointments were available within a day of a patient asking for one. Patients could often have an appointment within hours of requesting one.
- There was a strong focus on the wellbeing of patients at the practice, with many patients stating they feel cared for by all staff during their visits to the surgery.
- The whole practice had attended multiple learning and training events to enhance the care they provide to patients with additional needs, including blind, hearing and dementia awareness courses.
- Feedback received from patients, including those spoken to on the day, by telephone after the inspection, via the Care Quality Commission comments cards and through practice feedback methods, was highly positive.
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. However not all incidents were shared with the clinical team for learning and improvement.
- Most policies and procedures were up to date and clear for staff however some needed amendment such as prescription security arrangements needed to be reviewed.
- Most but not all staff had up to date appraisals however all overdue reviews were booked for completion.
- Staff understood about Mental Capacity but not had formal training in Mental Capacity Act 2005 awareness.
- 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.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw one area of outstanding practice:
- The practice demonstrated a highly caring ethos for all patients. Patients were respected and valued as individuals with emotional and social needs seen as important as their physical needs. Feedback from patients who use the service was continually positive with a strong visible patient centred culture.
- Patients were at the centre for arrangements in the practice such as for both routine and emergency appointments.
The areas where the provider should make improvements are:
- Review the safeguarding policy to display the correct name for the safeguarding lead.
- Review ways for improving prescription stationary security.
- Review the arrangements for staff appraisals.
- Reviewing the practice emergency medications such as the storing of Chlorphenamine onsite.
- Review the existing processes for reporting of significant events and near misses to ensure all events are recorded and subsequent learning from events can be shared across the practice.
- Review the plan for staff to have Mental Capacity Act 2005 training.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice