Archived: Dr Sarman Bapodra

Letter from the Chief Inspector of General Practice

REQUIRES IMPROVEMENT

We carried out an announced comprehensive inspection at Dr Sarman Bapodra – Belgrave Surgery on 20 January 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing effective and well led services. It also required improvement for providing services for all the population groups. It was good for providing a safe, responsive and caring service.

Our key findings across all the areas we inspected 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.

• Patients rated the overall experience of the practice as excellent. Urgent appointments were usually available on the day they were requested.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The practice had effective communication and good teamwork.

• Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.

• Information about services and how to complain was available and easy to understand.

• The practice had not proactively sought feedback from staff or patients.

The areas where the provider must make improvements are:

• Put in place an effective system to regularly assess and monitor the quality of the service provided by the practice.
• Ensure risks to patients are assessed and well managed. For example, risk assessments for, general office environment, control of substances hazardous to health (COSHH), use of a chaperone and infection control.
• Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.

• Ensure there are formal governance arrangements in place and staff are aware how these operate.

• Ensure staff have appropriate policies and guidance in place to carry out their role in a safe and effective manner which are reflective of the requirements of the practice. For example, a cold chain policy for ensuring that medicines are kept at the required temperatures, and describes the action to take in the event of a potential failure. There was no policy for repeat prescribing or shared care protocols with secondary care.
• Ensure audits of practice are undertaken, including completed clinical audit cycles.

In addition the provider should:

• Have full practice meetings which include the long term locums. The meeting should be regular, structured and relevant to give all staff the opportunity to take part in order for performance, quality and risk to be discussed.

• Have in place a robust infection control policy to provide staff with guidance.

• Have a process in place for staff to receive infection control training and education identified in the 2014 infection control audit.

• Disseminate national safety patient alerts (NPSA) to all staff.

• Carry out regular water checks to reduce the risk of legionella as identified in the legionella risk assessment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice