11 April 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Saptarshi Saha also known as Darlaston Health Centre on 25 May 2016. The overall rating for the practice was inadequate and the practice was placed in to special measures for a period of six months. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Saptarshi Saha on our website at www.cqc.org.uk.
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 11 April 2017. Overall the practice is now rated as good.
Our key findings were as follows:
- The practice operated effective systems for reporting and recording significant events. Significant event logs showed that the practice had responded and learned from safety incidents.
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Effective system were in place to receive and act on alerts from the Medical and Healthcare products Regulatory Agency (MHRA) alerts.
- At our May 2016 inspection, some medicines required to respond to medical emergencies were not stored within the practice. During this inspection we found that the arrangements to respond to medical emergencies had been strengthened.
- The practice had clearly defined and embedded systems to minimise risks associated with legionella, fire and health & safety.
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Overall Quality Outcomes Framework (QOF) performance remained above local and national averages. Uptake of bowl cancer screening had increased since the May 2016 inspection.
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Clinical guidelines were cascaded to all the clinical team; staff had the skills and knowledge to deliver effective care and treatment. The practice used clinical audits in most areas to monitor quality improvements. However, audits of completed joint injections were not being carried out.
- The July 2016 national GP patient survey showed areas where patient satisfaction had either increased or declined since the previous inspection. The practice were aware of these results and took actions to improve patient satisfaction.
- Completed Care Quality Commission comment cards showed that patients felt they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
- Information about services and how to complain was available. Previously complaints were not being managed effectively. During this inspection the practice were able to clearly demonstrate improvements made to the quality of care as a result of complaints and concerns. New ways of working were established in response to survey results.
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The practice had good facilities and was well equipped to treat patients and meet their needs.
- Staff felt supported by management. The practice had a number of policies and procedures to govern activity which staff had access to and held regular practice meetings. However, there were areas where oversight of some procedures were not carried out effectively such as managing uncollected prescriptions.
- The practice sought feedback from staff. The practice had an active patient participation group (PPG) and we saw measures in place in order to increase PPG membership and seek feedback from patients, which it acted on.
However, there were areas of practice where the provider should make improvements.
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Ensure staff are aware of practice policies and procedures and that these are adhered to and operated effectively.
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Establish an effective system for monitoring the overall stock of prescription stationery.
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Ensure clinical improvement initiatives are monitored to measure performance and quality improvements in all areas of need.
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Continue to consider ways of encouraging the uptake of national screening programmes such as bowel and breast cancer.
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Continue to review national GP patient survey results, internal patient feedback and explore effective ways to further improve patient satisfaction. Explore options to enable patients to be treated by a clinician of the same sex if and when requested.
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The practice should explore initiatives to improve engagement with patient groups where exception reporting is above local and national averages.
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Explore how to provide a service for patients who are unable to attend the practice.
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Ensure clinical performance initiatives are carried out to monitor quality improvements.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice