21 October 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection visit of Dr Rameshchandra Manilal Shah’s practice, at Thorns Road Surgery, in October 2015. As a result of our comprehensive inspection breaches of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified some areas where the provider must make improvements and additional areas where the provider should improve.
We carried out a focussed desk based inspection of Dr Rameshchandra Manilal Shah’s practice, at Thorns Road Surgery on 21 October 2016 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Rameshchandra Manilal Shah on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:
- Since our comprehensive inspection in October 2015, the practice had applied for disclosure and barring (DBS) checks for non-clinical staff members who chaperoned and for the practice nurse. We saw evidence to support this as part of our desk based inspection.
- Records demonstrated that the cold chain was appropriately monitored. Conversations with the practice manager also confirmed that the practice followed appropriate cold chain processes in line with national guidelines, such as appropriate temperature recording and ensuring that thermometers were reset after each recording.
- Regular fire drills were taking place and there were risk assessments in place to assess risks associated with infection control including a formal risk assessment for legionella.
- We also saw that risk had been assessed in the absence of a defibrillator and although the risk was assessed as low the practice had noted that they would prefer to purchase a defibrillator as soon as the funding became available.
The areas where the provider should make improvements are:
- The provider should ensure that in the absence of specific emergency medical equipment, risk is continually monitored and effectively mitigated to ensure that the practice can immediately respond to medical emergencies, for instance in the absence of a defibrillator.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice