Archived: Dr SS Sapre and Partners

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr S S Sapre & Partners on 26 November 2015. Overall the practice is rated as requires improvement. Specifically, we found the practice to require improvement for providing safe, effective and well led services. The practice is rated as good for providing caring and responsive services.

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. There were systems in place to mitigate safety risks including analysing significant events and safeguarding however they were not consistently applied.

• The premises were clean and tidy. Systems were in place to ensure medication including vaccines were appropriately stored and in date. Emergency medicines were readily available as was a defibrillator but the practice did not have oxygen available for use in an emergency.

• The recruitment procedure was not consistently followed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However the screening of patients at risk of dementia fell below the levels expected in a practice signed up to provide the enhanced service for dementia. The practice could not evidence care plans for these patients and could not produce minutes of multi-disciplinary team meetings for the care of palliative patients.
• 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.
• 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.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Although there was a clear leadership structure and staff felt supported by management, not all of the areas highlighted as requiring improvement had been focused on. The practice did not have a registered manager in place and could not demonstrate that this was being effectively dealt with. The lead GP could not demonstrate that the one day he spent at the practice was sufficient to allow full direction and control of the regulated activities.

There were areas were the provider must make improvements. The provider must:

• Ensure all recruitment checks as required by Schedule 3 are completed and copies of these checks are held in recruitment records.

• Ensure all significant events are reported, recorded and follow the written procedure for handling significant events.

• Apply the same level of scrutiny to complaints about clinical care, as would be applied to significant events ensuring lessons learnt are discussed and shared.

• Have oxygen in place for use in an emergency.

• Ensure a hearing loop is available for any patients who may need this.

• Carry out regular fire drills and keep records of these.

• Conduct a risk assessment on the need for Legionella checks and if required organise annual Legionella testing.

• Provide appropriate levels of screening for conditions, using appropriate tools.

• Ensure MDT meetings are held; where these are by telephone, keep appropriate records of these and minutes of all meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice