Dr A Cashyap and Partners Also known as Davenport House Surgery

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: safe, effective and well-led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: caring and responsive.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

• The practice’s systems for the appropriate and safe use of medicines, including medicines optimisation were not always comprehensive.
• The system for acting on safety alerts was insufficient.

Please see the final section of this report for specific details of our concerns.

We rated the practice as good for providing effective and well-led services because:

• Patients received effective care and treatment that met their needs. The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• The way the practice was led and managed promoted the delivery of high quality, person-centred care and an inclusive, supportive environment for staff. There was a focus on continuous learning and improvement at all levels of the organisation. Where we identified any concerns during our inspection, the practice took action to respond or plans of action were developed to ensure any issues were resolved.

The area where the provider must make improvements is:

• Ensure care and treatment is provided in a safe way to patients.

Please see the final section of this report for specific details of the action we require the provider to take.

The areas where the provider should make improvements are:

• Continue to strengthen policies, systems and processes at the practice. Especially those in relation to staff vaccinations, communicating with the Out of Hours service about safeguarding concerns, responding to instances of ‘was not brought’ children, monitoring and recording the collection of patient prescriptions for controlled drugs, and encouraging women to attend for their cervical screening.
• Implement a comprehensive system of staff appraisal and training to include all staff receiving an annual appraisal and completing all essential training in a timely way and at the appropriate level for their roles.
• Continue to take steps so that prescription stationery is always securely stored.
• Take steps so that water temperatures at the practice are within the required levels.
• Provide staff with access to a Freedom to Speak Up Guardian.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care