6 Feb 2019
During a routine inspection
We carried out an announced comprehensive inspection at Dr Sunita Bhalchandra Kulkarni on 6 February 2019 as part of our inspection programme.
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as requires improvement overall and good for all population groups except patients experiencing poor mental health which we rated as outstanding.
We rated the practice as requires improvement for providing a safe service. This is because:
- Not all staff had received safeguarding training at appropriate levels for their role.
- An effective employee immunisation programme was not in place.
- Fire drills had not been completed within the health centre since 2017 however false fire alarms had occurred and evacuation procedures followed appropriately.
- Regular reviews of a practice nurse’s prescribing had not been completed.
- A system was not in place to prevent the accidental interruption of the electrical supply to the vaccine refrigerator.
We rated the practice as good for effective, caring and responsive. This is because:
- Patients received effective care and treatment that met their needs.
- Staff worked together and with other organisations to deliver effective care and treatment.
- We rated the population group for patients experiencing poor mental health as outstanding for effective because the practice had developed effective tools to support and monitor patients who were suicidal.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
We rated the practice as requires improvement for well-led. This is because:
- Governance arrangements to ensure staff compliance with training were ineffective.
- Not all of the recommendations made at our previous inspection in November 2014 had been actioned.
- Several policies referred to by staff to support the governance of processes and systems at the practice had not been reviewed since 2014.
- The practice had not submitted a notification to the Care Quality Commission as required under the Care Quality Commission (Registration) Regulations 2009.
The provider must:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
The provider should:
- Provide protected learning time to support staff to complete their training.
- Carry out regular, planned fire safety drills.
- Update the business continuity plan to include appropriate contact numbers for services or staff.
- Review the Care Quality Commission (Registration) Regulations 2009 to support their understanding of incidents that are notifiable to the Care Quality Commission.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice