Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr SM Bhate and Dr H El-Shakankery on 12 December 2016. The overall rating for the practice was good, although the practice was rated as requires improvement for providing well-led services. We issued a requirement notice with respect to Regulation 17 on Good Governance because we found that processes were not in place to assess, monitor and improve the quality of service provided in carrying out the regulated activities for which the practice is registered. The full comprehensive report for the December 2016 inspection can be found by selecting the ‘all reports’ link for Dr SM Bhate and Dr H El-Shakankery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 7 February 2018 to review in detail the actions taken by the practice to improve the quality of care. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.
The practice is rated as requires improvement for providing well-led services, and overall the practice is rated as good.
Our key findings at this inspection were as follows:
- Although the practice had implemented an action plan to address the issues identified during the previous inspection not all of the required improvements had been made.
- The practice identified low numbers of internal significant events and the practice may not have always recognised events that had occurred that should be recorded and managed as significant events. This limited potential learning for the practice.
- The practice approach to the management of complaints had not improved. The practice did not record or manage verbal complaints and they failed to unsure patients were aware of the next steps they could take if they were unhappy with the outcome of a complaint.
At our previous inspection on 12 December 2016, we also told the provider that they should make improvements so that they followed their own policies and procedures when they recruited staff. In addition, we told the provider they should undertake regular checks to ensure that clinical staff were appropriately registered with the relevant clinical body. We saw at this inspection that improvements had been made:
- The practice had a process in place to ensure relevant recruitment checks were carried out and recorded. Records we checked confirmed that improvements had been made.
- The practice now had a process in place to undertake regular checks to ensure that clinical staff were appropriately registered. Records we checked confirmed this.
At this inspection, we found that there were some areas of practice where the provider still needed to make improvements. We also found that the practice’s registration with CQC was not up to date.
Importantly the provider must:
- Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity. For details, please refer to the requirement notice at the end of the report.
The areas where the provider should make improvements are:
- Complete the process for the registration of the partnership with the Care Quality Commission.
- Take steps to establish effective systems and processes of good governance in accordance with the fundamental standards of care in relation to the governance and management of significant events.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice