Goldington Road - Dr Das - Care Quality Commission

Background to this inspection

Updated 5 April 2017

Goldington Rd Surgery Dr Das provides a range of primary medical services, including minor surgical procedures from its location on Goldington Road in Bedford, on the town centre periphery.

The practice serves a population of approximately 3,000 patients with higher than average populations of males and females aged 0 to 14 and 25 to 44 years. There are lower than average populations of female patients aged 45 to 85 years and males aged 55 to 85 years. The practice population is of mixed ethnic origin, with high populations of Indian and Eastern European patients. National data indicates the area served is one of average deprivation in comparison to England as a whole.

The clinical team consists of two GP partners (one male and one female), a practice nurse and a health care assistant. The team is supported by a practice manager and a small team of administrative staff. The practice holds a General Medical Services (GMS) contract for providing services, which is a nationally agreed contract between general practices and NHS England for delivering general medical services to local communities.

The practice operates from a two storey converted Victorian property and patient consultations and treatments take place on the ground level and first floor. There is a car park to the rear of the surgery with designated disabled parking available at the front of the building.

Goldington Rd Surgery Dr Das is open between 8am and 6.30pm Monday to Friday. In addition, pre-bookable appointments are available until 8pm on Thursdays.

The out of hours service is provided by BEDOC (Bedfordshire Doctors on Call) and can be accessed via the NHS 111 service. Information about this is available in the practice and on the practice website and telephone line.

Overall inspection

Good

Updated 5 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Goldington Road Surgery Dr Das on 19 July 2016. The overall rating for the practice was requires improvement as breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – safe care and treatment.
Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – good governance.
Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – fit and proper persons employed.

From the inspection on 19 July 2016, the practice were told they must:

Ensure a suitably qualified person conducts a fire risk assessment and that all required actions are completed in a timely manner. Undertake fire drills routinely.

Ensure the newly developed recruitment policy is adhered to and that appropriate recruitment checks are performed for staff employed, including locums. All records relating to recruitment should be readily available for review.

Systems and processes must be established and operated effectively for assessing and mitigating risks.

In addition, the practice were told they should:

Develop a system to ensure all staff employed receive regular appraisals of their skills, abilities and development requirements.

Undertake regular infection control audits.

Implement the actions identified in the risk assessment relating to legionella.

Undertake planned work to improve access for patients with limited mobility, through the provision of appropriate amenities.

Develop systems to identify and support carers in their patient population.

The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Goldington Road Surgery Dr Das on our website at www.cqc.org.uk.

This inspection was a focused follow up carried out on 8 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 19 July 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

A suitably qualified person had been employed to undertake a fire risk assessment and all identified required actions had been completed in a timely manner. Including the installation of a fire alarm, emergency lighting and additional fire extinguishers. A system of routine maintenance and regular checks, including provision of regular fire drills had been developed.

The practice had improved governance arrangements to ensure that records were securely maintained and managed appropriately, in particular in relation to persons employed. Records relating to recruitment were readily available.

The practice had developed a risk management system and we saw evidence of risk assessment and actions taken is response to risks identified. For example, those relating to infection control. All risks identified in the legionella risk assessment had been completed in a timely manner.

All staff received regular annual appraisals and performance was monitored appropriately.

The practice had applied for funding to make improvements to the practice building with the intention of utilising any secured funds to improve disabled access, including but not limited to the provision of a disabled toilet.
The practice had improved available information for carers and had initiated a targeted effort to identify more carers in their population; increasing the number identified on the carers register from nine to 12. We were told that due to the amount of work undertaken in the months preceding our inspection; to ensure the practice met legal standards, the practice had been unable to dedicate resources toward identifying more carers. We were told that as all other improvement work reached completion the practice had started to make efforts to identify more carers, including changes to the patient registration form and creation of a dedicated carers form for completion. A noticeboard and carers information pack had also been updated.

The areas where the provider should make improvements are:

Continue with efforts to develop systems to identify and support carers in their patient population.
Undertake planned work to improve access for patients with limited mobility, through the provision of appropriate amenities.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice