The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Satya Kacker Also known as Broom Valley Medical Centre

Overall: Good read more about inspection ratings

102-104 Broom Valley Road, Rotherham, South Yorkshire, S60 2QY (01709) 365244

Provided and run by:
Dr Satya Kacker

All Inspections

9 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Satya Kacker on 2 June 2015. The overall rating for the practice was good with requires improvement for being safe. The full comprehensive report from June 2015 inspection can be found by selecting the ‘all reports’ link for 'Dr Satya Kacker' on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 March 2017 to confirm that the practice had addressed the areas for improvement recommended in our previous inspection on 2 June 2015. This report covers our findings in relation to those improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows: 

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Clinical audits demonstrated quality improvement.
  • There was evidence of appraisals and personal development plans for all staff.
  • The practice now had access to telephone interpretation services  for patients who did not have English as a first language. We saw notices in the reception areas informing patients this service was available. Patients were also told about multi-lingual staff who might be able to support them.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

2 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Satya Kacker’s practice on 2 June 2015. Overall the practice is rated as good.

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

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.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment and legionella risk assessment.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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 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.

We saw one area of outstanding practice:

The practice, in partnership with a local school, held an open afternoon once a year for school children to experience the day to day running of the surgery. They used this event to promote healthy living and to provide aspiration and inspiration for pupils to consider future employment in the health sector.

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

Importantly the provider should:

  • Ensure audits of practice are relevant to the patient population and improve patient outcomes. . Ensure recruitment arrangements include all necessary employment checks for all staff .
  • Ensure a legionella risk assessment is completed.
  • Ensure actions from incidents are completed in a timely manner.
  • Review the provision of oxygen on the premises.
  • Ensure all staff have an annual appraisal and the opportunity to meet with their line manager to discuss objectives, action planning and progress.
  • Review access to interpreting services for those patients who need it.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice