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Inspection summaries and ratings from previous provider


Overall summary & rating

Good

Updated 28 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Raksha Chopra’s practice on 31 August 2016. Overall the practice is rated as good.

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

  • Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.
  • 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.
  • The practice worked closely with other organisations in planning how services were provided to ensure that they meet patients’ needs.
  • We saw evidence to demonstrate that the practice had carried out an analysis of its patient population profile and developed targeted services and made changes to the way it delivered services as a consequence. For example by offering more in-house services such as diabetes care or 24 blood pressure monitoring.
  • Risks to patients were assessed and well managed.
  • Feedback from patients about their care was consistently positive. Patients we spoke with told us 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 28 September 2016

  • There was an effective system in place for reporting and recording significant events.
  • Outcomes and learning to improve safety in the practice had been shared with staff and were discussed at practice meetings. Information was disseminated to all staff.
  • When there were unintended or unexpected safety incidents, people received reasonable support, information, and a verbal apology where appropriate. They were also told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse. There was a lead member of staff for safeguarding children and vulnerable adults.
  • Risks to patients were assessed, embedded and well managed.

Effective

Good

Updated 28 September 2016

  • Unpublished and unverified data available from the practice for 2015/16showed that significant improvements had been made in areas where the p
  • There was evidence that audits were driving improvement in performance to improve patient outcomes such as in reducing antibiotic or hypnotics prescribing rates.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 28 September 2016

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this.
  • Data from the national GP patient survey showed patients rated the practice higher than others for most aspects of care.
  • We found that information for patients about the services available was easy to understand and accessible.
  • Patients we spoke with told us they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

Responsive

Good

Updated 28 September 2016

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example, the practice had engaged with the Clinical Commissioning Group (CCG) to provide relevant targeted in-house services for its patients.
  • Data from the national GP patient survey showed patients’ satisfaction with how they could access care and treatment was near or above local and national averages.
  • Patients were able to access appointments and services in a way and at a time that suited them. Patients we spoke with said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • The practice was equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised. Learning from complaints was shared with staff.

Well-led

Good

Updated 28 September 2016

  • The practice had a strategy to deliver high quality, personalised care in order to improve outcomes for patients. The practice was aware of performance levels and changes had been made where required.
  • There was a documented leadership structure and all staff felt supported by management.
  • The practice had a number of policies, procedures and systems to govern activity and held regular practice meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and improvements to the quality of care.
  • The practice had sought feedback from patients and the patient participation group was engaged and active.
  • All staff had received an appraisal with clear objectives documented.
Checks on specific services

People with long term conditions

Good

Updated 28 September 2016

  • Performance for diabetes related indicators for the practice in 2014/15 was 78% which was lower than the CCG average of 83% and national average of 84%. Exception reporting for the practice was lower at 6% compared with 11% for the CCG and 12% nationally. Data available from the practice showed that there had been a significant improvement for the year 2015/16 with the practice performance now at 95%. However, this was not published and verified data.
  • The practice had set up a pre-diabetic register and identified patients at higher risk of developing diabetes in order to support and advise patients on changes to prevent diabetes developing.
  • The percentage of patients on the asthma register, who had an asthma review for 2014/15, was below average at 56% for the practice compared to 74% for the CCG and 75% nationally. However, exception reporting was lower for the practice (3%, compared with 7% CCG & 8% nationally). Data available from the practice showed that there were had been a significant improvement for the year 2015/16 with the practice performance now at 100%. However, this was not published and verified data.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 28 September 2016

  • Same day appointments were available for children and those with serious medical conditions.
  • Immunisation rates for childhood vaccinations were in line CCG averages.
  • The practice’s uptake for the cervical screening programme was 80%, which was above the CCG average of 78% and same as the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies and baby changing facilities were available.
  • We saw positive examples of joint working with district nurses and health visitors.

Older people

Good

Updated 28 September 2016

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • A facility for online repeat prescriptions and appointments bookings was available.
  • Patients were also able to book telephone consultations with the GP.
  • A phlebotomy service was available at the practice for the convenience of patients requiring blood tests.
  • An electrocardiogram (ECG) service (equipment to record electrical activity of the heart to detect abnormal rhythms and the cause of chest pain) was available onsite at the practice.
  • There were longer appointments available for older patients and those over 75 were allocated a named GP.
  • There were disabled facilities available and the practice had a level access entrance to the premises.

Working age people (including those recently retired and students)

Good

Updated 28 September 2016

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • The practice offered extended hours on Tuesdays from 7pm to 8pm for working patients who could not attend during normal opening hours.
  • Patients could book appointments or order repeat prescriptions online.
  • Patients were able to book telephone consultations with the GP.
  • The practice offered a full range of health promotion and screening that reflected the needs for this age group.
  • The healthcare assistant conducted the health checks and gave advice on health promotion.

People experiencing poor mental health (including people with dementia)

Good

Updated 28 September 2016

  • Performance for mental health related indicators was 85% which was comparable to the CCG and national averages of 87%.
  • However, the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in 2014/15 was 79% for the practice compared to 90% for both the CCG and nationally. However, exception reporting was lower for the practice (0%, compared with 8% CCG and 10% nationally). Data available from the practice showed that there had been a significant improvement for the year 2015/2016 with the practice performance now at 88%. However, this was not published and verified data.
  • The practice maintained a mental health register on the clinical system.
  • Staff had received training on how to care for people with mental health needs.
  • The practice had informed patients experiencing poor mental health about how to access various support groups.
  • The GP we spoke with had knowledge of the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 28 September 2016

  • The practice held a register of patients living in vulnerable circumstances and alerts were in place on the clinical patient record system.
  • Translation services were available.
  • There were longer appointments available for patients with complex needs such as those with dementia or a learning disability.
  • There was a lead staff member for safeguarding and we saw evidence to show that staff had received the relevant training.
  • The practice had policies that were accessible to all staff which outlined who to contact for further guidance if they had concerns about a patient’s welfare.
  • Staff members we spoke with were able to demonstrate that they understood their responsibilities with regards to safeguarding.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.