19 January 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr UK Roy on 19 January 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice to require improvement for providing safe and effective services. It also required improvement for providing services for all the population groups. It was good for providing a caring, responsive and well led service.
Our key findings across all the areas we inspected were as follows:
- Not all staff understood their responsibilities to raise concerns, and to report incidents and near misses and the system in place for reporting incidents was not clear. Information about safety was not consistently recorded, monitored, appropriately reviewed and addressed.
- The practice did not have robust systems, processes and policies in place to manage and monitor risks to patients, staff and visitors to the practice.
- Data showed patient outcomes were average for the locality. Although some audits had been started, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
- Patients said 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.
- Urgent appointments were usually available on the day they were requested.
- The practice had a number of policies and procedures to govern activity, but there were some policies not in place.
- The areas where the provider must make improvements are:
- Ensure there is a robust system to manage and learn from significant events.
- Ensure audits of practice are undertaken, including completed clinical audit cycles.
- Ensure all staff have appropriate policies, procedures and guidance to carry out their role.
- Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service.
- Address identified concerns with infection prevention and control..
- Ensure confidential patient records are stored securely.
In addition the provider should:
- Review recruitment arrangements to include all necessary employment checks for all staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice