Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Zaw Thike on 5 April 2016. Breaches of the legal requirements were found. 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.

We undertook this desk based follow up inspection on 5 September 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. We reviewed written and photographic information sent to us by the practice that told us how the breaches identified during the comprehensive inspection had been addressed. This report should be read in conjunction with the full inspection report dated 5 April 2016. A copy of the last inspection report can be found on our website 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 Zaw Thike on 5 April 2016. Breaches of the legal requirements were found. 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.

We undertook this desk based follow up inspection on 5 September 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. We reviewed written and photographic information sent to us by the practice that told us how the breaches identified during the comprehensive inspection had been addressed. This report should be read in conjunction with the full inspection report dated 5 April 2016. A copy of the last inspection report can be found on our website www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We undertook this inspection visit to review infection control procedures in the practice. We reviewed records and systems and looked at the environment and how this impacted on the service delivery. We spoke with the practice manager.

We found that the improvements needed to achieve compliance had been made. People who used the service were protected from the risk of infection because appropriate guidance had been followed.

This inspection visit was undertaken by two compliance inspectors and a specialist advisor.

We used a number of different methods to help us understand the experiences of patients who used the service. We observed interaction between staff and patients. We reviewed records and systems and looked at the environment and how this impacted on the service delivery. We spoke with five patients who used the service. One patient was the chairman of the practice’s patient participation group. The practice manager, the practice nurse, a district nurse and district nurse manager, a medical secretary, two receptionists/medicine dispensers and the principle GP.

The appointment system in the practice had worked well for patients. Patient’s care needs had been assessed; they had time to discuss their health care issues, and had been fully involved in making decisions about their care and treatment.

Policies and procedures were in place to protect vulnerable adults and children. However, not all the staff in the practice had received training to ensure they had an understanding of what constituted abuse.

Patients told us the practice was always clean. They could remember that seeing clinical staff had washed their hands before examining them or carrying out a procedure. However, we found that risks associated with cross infection had not been fully assessed.

Procedures were in place to respond to complaints and review the quality of the service provided.