28 January 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Dzung Nguyen (The Yellow Practice) on 28 January 2016. Overall the practice is rated as requires improvement.
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. However, investigations and analysis were not documented in a way which showed they had been shared with staff. Patients did receive a verbal and written apology when things went wrong.
- Risks to patients were assessed and well managed, with the exception of those relating to the security of prescription pads.
- Clinical governance meetings were not attended by all clinical staff and the meetings were not minuted to ensure all staff were aware of discussions which took place.
- There were some gaps identified in staff training particularly for health and safety related subjects and governance.
- The majority of patients said they were treated with compassion, dignity and respect.
- 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.
- 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 complied with the requirements of the Duty of Candour.
- The practice had proactively sought feedback from patients and had an active patient participation group.
The areas where the provider must make improvements are:
- Ensure that mandatory training for staff is completed and monitored to ensure that time frames for renewal do not lapse. This includes ensuring staff have completed relevant training for fire safety, infection control, basic life support and information governance.
In addition the provider should:
- Review the systems in place for patients who have complained to ensure they receive further signposting to information should they wish to continue with their complaint.
- Ensure all staff are aware of the translation service available for patients who do not have English as a first language.
- Review the equipment available for use in medical emergencies, particularly for children.
- Consider the recording of minutes for meetings are maintained to assist in effective governance and ensure these are distributed to staff to inform better information sharing across all staff teams.
- Review the patient satisfaction results within the National GP Survey and consider what changes could be made to the areas that are lower than other practices so as to ensure greater satisfaction for patients.
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Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice