Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A S Pannu and Partners on 9 September 2015. Breaches of the legal requirements were found in relation to routine checking of emergency equipment to ensure it was fit for purpose and the practice’s risk assessment for legionella did not cover the risk of an unused shower in one of the branch practices.

As a result, care and treatment was not always provided in a safe way for patients and the registered provider’s system to routinely check the equipment used in emergencies and appropriately assess the risk of legionella was not safe. Therefore, a Requirement Notice was served in relation to Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation12 Safe care and treatment.

Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breaches and how they would comply with the legal requirements, as set out in the Requirement Notice.

Additionally, the practice was rated as requires improvement in the Caring domain as the practice had not responded to low scores in the national GP patient survey, in order to improve services. The practice were also informed of improvements it should make in relation to:

• Reviewing and risk assessing how controlled drugs were recorded, in order to ensure good practice guidance is followed.

• Reviewing the storage of equipment to be used in emergencies, in order for it to be to be located in one accessible place.

• Reviewing the process for nurse appraisals, in order to ensure they are conducted annually.

We undertook this desk based inspection on 12 April 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. 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 A S Pannu and Partners on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A S Pannu and Partners (also known as St Georges Medical Centre) on the 9 September 2015. During the inspection we gathered information from a variety of sources. For example, we spoke with patients, interviewed staff of all levels and checked that the right systems and processes were in place.

Overall the practice is rated as requires improvement. Specifically, we found the practice to require improvement for providing safe services. It was good for providing effective, responsive and well-led services.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group.

• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.

• Staff had received training appropriate to their roles and any further training needs had been identified and planned. However, nurse appraisals had not been conducted.

• The practice had not proactively responded to low scores in the National Patient survey, in order to improve services.

• The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that the system to routinely check the equipment used in emergencies is safe. In order to ensure it is within its expiry date, sterile and fit for purpose.

• Ensure that action is taken to reduce the risk of legionella.

In addition the provider should:

• Review and risk assess how controlled drugs are recorded, in order to ensure good practice guidance is followed.

• Review the storage of equipment to be used in emergencies, in order for it to be to be located in one accessible place.

• Review the process for nurse appraisals, in order to ensure they are conducted annually.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice