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Archived: Dr SS Sapre and Partners Requires improvement

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Reports


Inspection carried out on 13 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr S S Sapre & Partners on 13 January 2016. Overall the practice is rated as requires improvement.

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

  • The practice had a system in place for the management of Medicines and Healthcare Products Regulatory Agency (MHRA) alerts. However, there was a delay of up to one week before these were shared with clinicians. These alerts were not held for future reference.

  • Arrangements for managing medicines kept patients safe.

  • The practice had completed a number of clinical audits which evidenced safe prescribing.

  • Assurances given by the provider in response to the findings of an infection control audit at the practice had not been acted upon.

  • At the time of inspection, the practice was carrying vacancies for a health care assistant and a permanent GP.

  • Staff recruitment checks were incomplete; a number of staff had not received an induction and some staff had not received the appropriate employment contracts.

  • There was no oxygen available for use on site. The practice manager pointed to the availability of oxygen at neighbouring facilities but could not confirm or show there was an agreement in place for shared use of oxygen.

  • No care plans were in place for patients aged over 75 who may be more vulnerable to ill health .

  • Dementia screening was being done opportunistically. There was no plan in place to show how all patients identified as being at risk of dementia, would be effectively screened in a timely manner.

  • The practice did not have an efficient system in place to manage the health checks for patients aged 40-74 years.

  • Complaints submitted to the NHS Choices website were not followed up and acted upon. All complaints were not recorded.

  • The registration of the practice with the Care Quality Commission did not reflect the way in which the practice was run; the lead GP was present at the practice for two clinical sessions each week. Evidence from our inspection showed that this was insufficient to maintain overall direction and control of the practice.

There were areas were the provider MUST make improvements. The provider must:

  • Ensure care plans are in place for patients aged 75 and over.

  • Ensure there is access to oxygen for use in medical emergencies.

  • Improve systems in place for the management and sharing of MHRA alerts.

  • Effectively address points raised in the infection control audit by Liverpool Community Health.

  • Record, investigate and respond to all complaints made about the practice, whether they are verbal or written, or registered on the NHS Choices website.

  • Keep sufficient records in relation to staff recruitment.

  • Keep sufficient records in relation to the management of regulated activities.

  • Address issues around the registration of the practice.

There were areas were the provider SHOULD make improvements. The provider should:

  • Provide a hearing loop facility for those patients with impaired or reduced hearing.

  • Review all patient deaths (death audit) to ensure patients wishes around final place of care are observed.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice