Archived: Dr Patrick Gonsalves Also known as Kingstanding Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced inspection at Kingstanding Road Surgery on 23 February 2015, when the practice was rated as inadequate and placed into special measures. This was followed up with an inspection on 21 October 2015 to determine if actions had been completed in response to warning notices issued as a result of the previous inspection.

We found on the inspection on 21 October 2015 that improvements had been made but the rating was not changed as a new comprehensive inspection was required in line with CQC process. Therefore, we carried out an announced comprehensive inspection at Kingstanding Road Surgery on 29 January 2016 to determine if sufficient improvements have been made to allow the practice to be taken out of special measures and review the practice rating.

Following the inspection carried out on 29 January 2016 the overall rating of the practice is good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• 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.
• 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 and that there was continuity of care, with urgent appointments available the same day.
• The practice had adequate facilities and had the appropriate equipment and resources to treat patients and meet their needs.
• The practice had joined with Modality Partnership and were in the process of amending their CQC registration. This had resulted in a clear leadership structure and management model. Staff reported that they felt supported by management.
• The practice proactively sought feedback from staff and was seeking to engage with patients to gain their views and act on them. For example, by raising awareness in the waiting area regarding feedback. They were taking steps to re-establish the patient participation group.

The areas where the provider should make improvement are to:

• Carry out risk assessments regarding emergency equipment and contents of GPs bags.
• Continue to carry out audit to monitor and demonstrate improvement in patient outcomes.
• Proactively seek to identify carers in the practice.

I confirm that this practice has improved sufficiently to be rated ‘Good’ overall. The practice will be removed from special measures.

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 focused inspection at Dr Patrick Gonsalves’ practice on 21 October 2015. This inspection was to follow up warning notices we issued after a comprehensive inspection on 23 February 2015, which resulted in an overall rating of inadequate.

We found the provider to be in breach of the following regulations:

• Regulation 17: Good governance
• Regulation 19: Fit and proper persons employed

As this was a follow up inspection we looked at specific areas to see if improvements had been made following our previous inspection. A third party provider was working with the practice with a view to forming a partnership. It was evident that the improvements to meet the warning notice requirements had taken place since their involvement with the practice.

As this inspection was to focus on the warning notice the original rating remains. This will be reviewed at the comprehensive inspection.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Staff understood their responsibilities for the management of patient safety alerts; information was recorded, monitored, appropriately reviewed and addressed.
• The practice had a number of newly developed policies and procedures to govern activity and staff had access to these via the practice computer system. The practice had implemented governance meetings, where issues were discussed. Two meetings had been held prior to our inspection.
• The Infection Prevention and Control (IPC) lead had been identified; they had not received training to undertake this role. The practice had completed one infection control audit and developed an action plan.
• All staff were up to date with basic life support training, but not infection prevention and control (IPC), chaperone training and other training relevant to their roles.
• Recruitment checks for staff had been completed and where gaps were identified these were being addressed.
• Staff felt supported by management. The practice had started to proactively seek feedback from staff and patients.
• A fire risk assessment, fire alarm tests and fire drills had been completed.
• The practice had not undertaken regular staff appraisals

However there were areas of practice where the provider needs to make improvements.

The provider should:

Ensure suitable arrangements are in place to support staff appropriately to deliver care and treatment safely by receiving suitable training and appraisal.

Ensure that policies and procedures are maintained and up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice