- GP practice
Archived: Dr Sharma and Partners
All Inspections
15 May 2018
During a routine inspection
This practice is rated as Good overall. (Previous inspection 06 September 2016 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Dr Sharma and partners on 15 May 2018 as part of our inspection programme.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- There was an active patient participation group in place who felt listened to and valued.
- Staff were positive about working in the practice and felt valued and supported in their roles.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are to:
Review and improve recording and management of staff records including the recording of verbal references, monitoring of staff medical indemnity cover and recording and management of training records.
Carry out training on the identification of red flag signs of sepsis with non-clinical staff.
Monitor the security of blank printer prescriptions in consultation rooms.
Complete an updated fire risk assessment record, carry out any actions identified and carry out, record and action a separate general health and safety risk assessment.
Continue to monitor and improve patient satisfaction.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
06 September 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Dr Elias and Partners on 15 December 2015. Breaches of legal requirements were found during that inspection within the safe domain. The practice was rated as good overall, requires improvement in the safe domain and good in the effective, caring, responsive and well-led domains. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements. We undertook a focused inspection on 06 September 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and was rated as good overall and good under the safe domain. This report only covers our findings in relation to those requirements.
During the previous inspection on 15 December 2015 we found that the areas where the practice must make improvements were:
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To ensure that all staff received training in the safeguarding of children and vulnerable adults and also fire safety training.
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To carry out rehearsals of fire safety and evacuation procedures on a regular basis.
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To obtain mercury spillage kits if intending to continue using instruments containing mercury.
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To ensure that maximum and minimum temperatures were recorded daily on all fridges and that action was taken if temperatures were found to be outside the recommended ranges.
This report should be read in conjunction with the last report from 15 December 2015. The report from our last comprehensive inspection can be read by selecting the 'all reports' link on our website at www.cqc.org.uk
During this inspection we found that:
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All staff had received vulnerable adult and child safeguarding training to a level appropriate to their role. All staff had received fire safety training.
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A fire safety and evacuation rehearsal had taken place and learning points had been discussed and recorded.
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The practice had purchased mercury spillage kits.
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Maximum and minimum fridge temperatures were recorded daily for all fridges.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
15 December 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Elias and partners on 15 December 2015. 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. The practice had identified some issues with their processes for analysing significant events and had been proactive in taking action to resolve them.
- Risks to patients were assessed and well managed, with the exception of some aspects of fire safety. A recent fire risk assessment had been carried out, however not all staff had received fire safety training and there had not been a recent rehearsal of fire safety and evacuation procedures.
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The practice had clear values, aims and objectives which staff identified with and understood.
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Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- Urgent appointments were available on the day they were requested.
- Information about services and how to complain was available and easy to understand.
- 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.
- The practice had a history of innovation and continuous improvement. They had been involved in several clinical pilot schemes and were regularly involved in research projects.
- Nursing staff had all had regular documented appraisals.
- All reception and administrative staff appraisals for 2015 had been commenced but not yet completed.
- Not all staff had received training in the safeguarding of children and vulnerable adults.
- Medicines were generally managed well, however the temperatures in one fridge (which did not contain vaccines) had not been recorded regularly or action taken when recordings were made outside the normal range.
- There were mercury containing sphygmomanometers on the premises (equipment used to measure blood pressure manually), but no mercury spillage kit was available.
The areas where the provider must make improvement are:
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To ensure that all staff receive training in the safeguarding of children and vulnerable adults and also fire safety training.
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To carry out rehearsals of fire safety and evacuation procedures on a regular basis.
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To obtain mercury spillage kits if intending to continue using instruments containing mercury.
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To ensure that maximum and minimum temperatures are recorded daily on all fridges and that action is taken if temperatures are found to be outside the recommended ranges.
The areas where the provider should make improvement are:
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To monitor changes that have been made in the processes of significant event analysis.
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To ensure that the reception and administrative staff appraisals for 2015 are completed and are repeated on a regular basis.
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Review and update practice policies and risk assessments on a regular basis.
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Review their policy with regard to the handling of verbal complaints.
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Review ways to improve patient access to their preferred GP.
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To introduce a systematic programme for future audits and formalise discussion and learning from audits.
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Complete the registration process for the addition of the regulated activities Maternity and Midwifery Services and Family Planning Services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice