Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Kaura and Partners on 17 March 2016, which resulted in the practice being rated as good overall but as requiring improvement for providing effective services. The full comprehensive report can be found by selecting the ‘all reports’ link for Dr Kaura and Partners on our website at

www.cqc.org.uk

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This inspection was a desk-based review carried out in December 2016 to confirm that the practice had carried out steps to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection in March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

• Since our previous inspection staff had completed all mandatory training. A training matrix was in operation to help identify gaps or when updates were due.

• Unless specifically requested by the patient making the complaint, complaints information was not stored on a patients medical record.

• A system was now in place to ensure all meetings were minuted and minutes saved where they could easily be accessed by staff

• The practice had obtained documentary evidence confirming that NHS Property Services had carried out relevant Health and Safety checks. However, the last legionella risk assessment, carried out in July 2012, had highlighted some action points and the accompanying report, which was produced in July 2014 had recommended that a re assessment be carried out every two years. When this was pointed out to the practice during the inspection they contacted NHS Property Services to obtain a more up to date copy. However this was not received before finalising this report.

The practice should therefore:

• Put steps in place to monitor when health and safety checks are due to be completed by NHS Property Services, follow up on any delays or gaps and ensure they retain a copy on site of all up to date documentation.

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 Kaura and Partners on 17 March 2016. Overall, the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons were learned when incidents and near misses occurred. However, record keeping of the meetings where these issues were discussed was limited.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, we found some training previously completed by staff needed updating in line with the latest guidance and some training still needed to be completed. 
• Outcomes for patients were good. The Quality and Outcomes Framework (QOF) data, for 2014/2015, showed the practice had performed very well in obtaining 99% of the total points available to them for providing recommended care and treatment.
• 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. However, the storage of information that related to complaints was not managed in line with their agreed complaints policy.
• 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.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Extended hours appointments were available with a GP on three mornings a week and five mornings a week with a nurse or healthcare assistant.
• 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 had complied with the requirements of the duty of candour regulation.

There is one area where the provider must make improvements:

The provider must:

• Ensure staff update or complete all of the training required for their roles in line with the latest guidance.

There are three areas where the provider should make improvements:

The provider should:

• Review the management of complaints at the practice. The storage of information that related to complaints should be managed in line with their agreed complaints policy.
• Ensure that appropriate records are maintained in relation to the governance of the practice, specifically in relation to records of meetings and the recruitment of staff.
• Ensure they have documentary or electronic evidence which confirms that NHS Property Services have completed the health and safety checks they are contracted to carry out.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice