Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Amrish Gor (Havergal Surgery) on 7 July 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed. However the practice had not carried out a full health and safety risk assessment and could not provide evidence of any previous assessments.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However non-clinical staff were in need of updating information governance training and clinical staff had not received formal training on the Mental Capacity Act 2005 despite being able to show a working knowledge of this.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• There was no programme of quality improvement through continuous clinical audit.
• We found that a number of published QOF domains were lower than the National/CCG average although we were provided with some evidence that improvements had been made albeit relating to unverified and unpublished data.
• 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 with a named GP and there was continuity of care, with urgent appointments available the same day.
• Not all staff acting as chaperones had a Disclosure and Barring Service (DBS) check. However for some staff this had been applied for in June 2016.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. 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.

The areas where the provider should make improvement are:

• Carry out a health and safety risk assessment for the practice.

• Implement a continuous programme of quality improvement including clinical audit, to include review of QOF performance and patient coding.

• Update staff information governance and mental capacity act training.

• Ensure that staff roles are appropriately risk assessed such that staff who act as chaperones are checked against the DBS register.

• To investigate ways to improve cervical smear results.

• To review how the practice identifies patients with caring responsibilities to ensure information advice and support is available.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating July 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Amrish Gor as part of our inspection programme.

At this inspection we found:

That the provider had effective governance processes in place, risk was well managed and there was evidence of improvements to patient care.

For example:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Ensure a fire risk assessment is completed annually and all fire drills are recorded in the fire drill log.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.