The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Surjit Dhillon Also known as Limbrick Wood Surgery

Overall: Good read more about inspection ratings

Tile Hill Health Centre, Jardine Crescent, Coventry, West Midlands, CV4 9PN (024) 7646 0800

Provided and run by:
Dr Surjit Dhillon

Important: The provider of this service changed. See new profile

All Inspections

26/07/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Surjit  Dhillon (also known locally as Limbrick Wood Surgery) on 26/07/2016. Overall the practice is rated as 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 been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.

  • Patients said they found it easy to make an appointment with the 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 practice proactively sought feedback from staff and patients, which it acted on.

  • The provider was aware of and complied with the requirements of the duty of candour.

We saw an area of outstanding practice:

The practice provided a high level of support to vulnerable people. For example:

  • The practice had helped to set up a ‘tea and talk’ support group within the health centre, and continued to refer elderly, socially isolated and recently bereaved patients of the practice to this group. This group had been running for over 15 years and continued to meet weekly.

  • The practice held a carers’ clinic twice a month. This clinic was attended regularly by patients of the practice and provided support and advice for them. The practice was the first in Coventry to offer this service in 2009, and following the success of this initiative other practices decided to set up similar sessions locally which has led to increased provision of services for carers in the area.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

At our last visit on 18 and 20 June 2013 we saw that improvements were needed to the recruitment and selection processes used at the practice.

We asked the provider to send information to us to show that improvements had been made in both areas of non-compliance. We checked the information we received.

The information showed that an effective recruitment and selection process had been put in place to ensure patients were kept safe from the risk of harm.

18, 20 June 2013

During a routine inspection

We spoke with three patients, the provider, the practice nurse and practice staff. The patients we spoke with said that overall they were satisfied with the service provided.

We saw that the practice had a high numbers of patients for the current GP list. This meant there was a reduced number of appointment slots being offered to patients. This was confirmed by the patients we spoke with. We were told that the practice was currently advertising for a new GP.

We found some gaps in staff recruitment processes as some pre-employment checks had not been completed for new staff. This could potentially put staff and patients at risk.

One patient told us, 'I always feel involved in decisions about me. It didn't used to be like that but is better now'. Another patient told us how the GP had explained all the risks to them prior to having a surgical procedure. This shows that patients are being informed and kept involved in their care and decisions when they need to be made.

We found that good communication and referral pathways existed between the medical practice and other healthcare professionals.

Patients from the practice told us that the practice was 'clean and tidy' and that they had no concerns in this area. We saw appropriate guidance was in place for staff to follow and that the last infection control audit had taken place in February 2013. We noted that the practice did not have an identified planned infection control audit schedule in place.

Systems were in place to manage and monitor complaints, clinical incidents and serious untoward incidents. This meant that patient's views were being taken into account.