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 (Maghull Health Centre) on 2 February 2016. Overall the practice is rated as requires improvement.

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

• The practice had a system in place for the management of Medicines and Healthcare Products Regulatory Agency (MHRA) alerts.

• Arrangements for managing medicines kept patients safe.

• The practice had completed a number of clinical audits which evidenced safe prescribing.

• Assurances given by the provider in response to the findings of an infection control audit at the practice had not been acted upon.

• At the time of inspection, the practice was carrying a vacancy for a permanent GP.

• Some references for staff had not been followed up. Some staff had not received an induction, appraisal or the appropriate employment contracts.

• There was no oxygen available for use on site.

• The practice performed well in terms of QOF (Quality and Outcomes Framework) performance, achieving 97% of points available for 2014-15.

• The practice had introduced a simple system to mark records of those patients who had declined the offer of cytology screening, which made exception reporting for this intervention transparent.

• The practice did not have an efficient system in place to manage the health checks for patients aged 40-74 years. The practice gave the figure of 273 health checks completed on patients between 40-74 years, out of a total patient list for the two practices within the same building owned by Dr Sapre, of approximately 4,800 patients.

• Comment cards completed by patients before our inspection indicated that the practice and staff were caring, and treated patients with dignity and respect.

• Complaints submitted to the NHS Choices website were not followed up and acted upon.

• The provider had failed to deal effectively with an IT issue which had been ongoing for six months.

• The division of responsibilities between leaders was unclear. Staff were unsure of how patient registers were produced. The carers register was inaccurate.

• The registration of the practice with the Care Quality Commission (CQC) did not reflect the way in which the practice was being run. This had not been addressed.

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

• Ensure there is access to oxygen for use in medical emergencies.

• Effectively address points raised in the infection control audit by Liverpool Community Health.

• Record, investigate and respond to all complaints made about the practice, whether they are verbal, written, or registered anonymously.

• Keep sufficient records in relation to staff recruitment.

• Keep sufficient records in relation to the management of regulated activities.

• Ensure the registration of the practice with the Care Quality Commission (CQC) accurately reflects the way in which the practice is being run.

There were areas were the provider SHOULD make improvements. The provider should:

• Provide a hearing loop facility for those patients with impaired or reduced hearing.

• Review patient deaths (death audit) to ensure patient’s wishes around final place of care are are observed.

• Have care plans are in place for patients aged 75 and over.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice