Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr N Pillai and Dr L Nair on15 October 2015. Overall the practice is rated as good.

Specifically, we rated the practice as good for providing safe, effective, caring, responsive and well led services. The service provided to the following population groups was rated as good:

• Older people

• People with long-term conditions

• Families, children and young people

• Working age people (including those recently retired and students)

• People whose circumstances may make them vulnerable

• People experiencing poor mental health (including people with dementia).

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• 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.

We saw areas of outstanding practice, these were:

• There were examples of how the practice had responded to the needs of vulnerable patients with compassion and empathy. The practice told us that they had supplied a stair lift for a patient from their donation funds when other services were unable to. We saw a letter from the patients carer thanking the practice for their support and that it had made a positive impact on their life.

• The practice was proactive in completing clinical audits that demonstrated quality improvement. There was evidence that clinical audits were effective in improving outcomes for patients. For example, an audit identifying patients who were at risk of high cholesterol due to family history, asthma diagnosis in children, minor surgery audits and an audit on spirometry rates.

However, there was an area of practice where the provider needs to make improvements.

The provider should :

• Review the health and safety risk assessment completed in May 2014 so that potential risks are assessed and managed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr N Pillai and Dr L Nair (known as St Luke’s Surgery) on 13 December 2018 as part of our inspection programme. The practice was last inspected in October 2015 and rated as good.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. For example: the practice had signed up to the IRIS (Identification and Referral to Improve Safety) project, regular practice education sessions and development of staff through external training opportunities.

Whilst we found no breaches of regulations, the provider should:

• Update the safeguarding policy to include information about modern slavery.
• Improve the identification of carers to enable this group of patients to access the care and support they need.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice