- GP practice
Archived: Dr Kirit Shah Also known as The Vauxhall Surgery
Important:
The provider of this service changed. See new profile
All Inspections
3 July 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Dr Kirit Shah on 3 February 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulations 9 (Person centred care); 12 (Safe care and treatment); 13 (Safeguarding service users from abuse and improper treatment); 17 (Good governance) and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook a focussed inspection on 1 December 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. We found that there remained one breach of regulation in relation to regulation 17, good governance.
You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Kirit Shah on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 3 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 1 December 2016. This report covers our findings in relation to those requirements.
Overall the practice remains rated as Good. The rating for providing Effective care is now Good. Our key findings were as follows:
- Clinical audits had been carried out and completed with a second cycle. Clinical audits related to NICE guidelines and resulted in changed and better outcomes for patients.
- The practice monitored that these guidelines were followed through, for example, regular discussion at clinical meetings. We saw copies of minutes of these meetings.
- We reviewed a number of care plans and found them to be well documented.
- Clinical staff participated in multi-disciplinary meetings where the needs of specific patients were discussed and the opportunity given to discuss concerns, issues and ongoing care.
- We found that the practice had adequate levels of clinical staff, through the use of a long term locum GP and a locum practice nurse to supplement the existing practice nurse availability. However, we noted that patients did not have access to a female GP, the long term female locum GP having recently left the practice.
At our initial inspection on 3 February 2016 we found a number of single use pieces of equipment that were of out of date. We found similar issues when we re-inspected on 1 December 2016. Disappointingly, at the visit on 3 July 2017 we again found out of date dressings, blood test tubes, blood collection kits and a stitch cutter. This was in spite of the provider telling us they had a new standard operating procedure template in place to use to carry out equipment checks. The provider needs to make improvements in this regard, as outlined below.
Importantly the provider should:
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Keep under review the lack of access to a female GP to ascertain if the needs of patients are being met in this regard.
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Review the process for checking single use equipment to ensure the system is robust.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
1 December 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Dr Kirit Shah on 3 February 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulations 9 (Person centred care); 12 (Safe care and treatment); 13 (Safeguarding service users from abuse and improper treatment); 17 (Good governance) and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook this focussed inspection on 1 December 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Kirit Shah on our website at www.cqc.org.uk.
Overall the practice was rated as requires improvement following the comprehensive inspection. They were rated as requires improvement for providing safe, effective and well led services. Following this focussed inspection we found the practice to be good for providing a safe and well led service. It remains rated as requires improvement for effective services as the practice had not yet demonstrated an effective quality improvement programme, for example two cycle, completed audits.
Our key findings across all the areas we inspected were as follows:
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The practice had put processes in place to ensure that staff were up to date with training, including basic life support.
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The practice had taken action to address the risks to the health and safety of patients. For example it had purchased a defibrillator and oxygen, had ensured its medicines were in date and had updated its emergency equipment.
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We found several out of date single use items of equipment.
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The GP and practice nurse had undergone training in care planning and we saw that care plans were much improved.
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Staff had undergone training in safeguarding adults and children. Staff were familiar with the local referral process.
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The practice had taken action to evaluate and improve the effectiveness of their clinical systems and the service provided to patients. A number of clinical audits had been commenced.
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Regular supervision was being carried out for all staff and we found that staff were carrying out roles appropriate to their training.
The area where the provider must make improvement is to:
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Ensure quality improvement initiatives are embedded in the practice in order to monitor and improve the quality of care delivered.
The area where the provider should make improvement is to:
- Review the process for checking single use equipment to ensure the system is robust.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
3 February 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Dr Kirit Shah on 3 February 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.
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Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe.
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Data showed most patient outcomes were comparable to local and national averages.
- Only one completed audit had been carried out. We saw no evidence that audits were driving improvement in performance to improve patient outcomes.
- The majority of patients said they were treated with compassion, dignity and respect. They said they felt cared for, supported and listened to.
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Information about services was available, and one information leaflet was in Portuguese to cater for the large number of Portuguese patients on the practice list.
- Urgent appointments were usually available on the day they were requested.
- The practice had a number of policies and procedures to govern activity, but some were overdue a review.
- The practice had proactively sought feedback from patients and had an active patient participation group.
The areas where the provider must make improvements are to:
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Ensure staff receive safeguarding training and are familiar with the process to make referrals.
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Determine the immunisation status of all relevant staff, and in particular those with close patient contact.
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Ensure staff do not work outside the scope of their training and qualifications.
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Ensure all medicines and equipment are in date.
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Carry out a risk assessment with regard to the decision not to have a defibrillator on site.
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Ensure the practice has oxygen on site.
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Provide staff with basic life support training.
- Carry out regular and systematic clinical audit, including quantitative audits of the care of groups of patients against defined criteria (with re-audit to demonstrate change).
- Provide clinical and non clinical staff with regular supervision.
- Ensure patient care plans are correctly documented.
In addition the provider should:
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Ensure patient group directions are appropriately dated, in line with legislative guidance.
- Record details of verbal employment references and record new staff induction.
- Improve the system to record the cleaning carried out by the cleaning contractor so that the practice can determine what has been cleaned and when.
- Review regularly and update procedures and guidance.
- Review the system for dissemination of safety alerts and clinical guidance across the practice.
- Review staff training needs, including infection prevention and control and Deprivation of Liberty Safeguards training.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice