Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 9 and 15 February 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet their legal requirements in relation to the breach of regulation 12(1) (2) Safe care and treatment and regulation 19 (3) Fit and proper person employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 17 October 2016 to check that the practice had followed their plan and to confirm that they were now meeting their legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Avinash Kumar Sennik on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe and responsive services. This affected the ratings for all of the population groups which are now good.

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

• Risks to patients were assessed and well-managed, including those related to recruitment checks, fire safety and infection control.

There were areas of the practice where the provider should make improvements:

• Review practice procedures to ensure safeguarding vulnerable adults training is provided to all staff.
• Review practice procedures to ensure written references are obtained for all staff before employing them.
• Review the telephone system in the practice to ensure telephone access for patients is improved. 

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 Avinash Kumar Sennik on 9 and 15 February 2016. Overall the practice is rated as requires improvement.

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, with the exception of those relating to recruitment checks and infection control audits not being undertaken.
• Feedback from patients reported that access to a named GP and continuity of care was not always available quickly, although urgent appointments were usually available the same day.

• Access to the service showed that patients were not able to see a GP until the first appointment at 10am. Although the practice telephone lines opened at 8am.

• Practice specific policies were implemented and were available to all staff. But not all policies had been signed or were dated and the version control verified.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Ensure an annual audit of infection prevention and control are undertaken.

In addition the provider should:

• Ensure that GP survey results are reviewed to address low scoring areas and improve patient satisfaction with consultations.

• Review the times of clinical staff availabilityto meet patients needs.

• Ensure patients identified with caring responsibilities are provided with appropriate support.

• Implement systems to ensure policies and guidance documents are reviewed and updated as necessary.

• Ensure that annual fire drills are recorded and documented.
• Ensure information in the patient leaflet is up to date to reflect the current service.
• Ensure the discussions and actions agreed in PPG meetings are documented to enable dissemination to others and enable an audit trail of decisions.
• Ensure safeguarding vulnerable adults training is provided to staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice