12 August 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Kanwalpal Nandra’s practice on 12 August 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
- The practice had identified risks and had implemented systems to mitigate risks.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. 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.
- We saw that outcomes for patients were in line with national standards.
- Regular multi-disciplinary team meetings were in place at the practice.
- The practice provided extended access on Monday evenings and had adapted the practice to meet the needs of all patients.
- 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.
- Governance arrangements were in place at the practice, but in some instances outcomes of meetings and policies and procedures were not documented.
The areas where the provider should make improvements are:
- Ensure that clinical meetings at the practice are minuted.
- The practice should ensure that all policies and guidance at the practice are specific to the practice.
- The practice should ensure that planned measures to change the flooring in the clinical rooms in the practice takes place as soon as possible.
- The practice should ensure that fire tests and drills are carried out and a record of these checks is maintained.
- The practice should ensure that it proactively seeks feedback from patients and that it meets regularly with the patient participation group.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice