26 August 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Karim Mashayekhy also known as The Village Surgery on 26 August 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
- Risks to patients were generally assessed and well managed. However, the practice had not carried our regular fire drills and fire extinguishers were not being checked annually by a recognised fire safety service, although the practice arranged for this following our visit. There was no current building electrical safety certificate and only clinical items of equipment had been electrically tested to ensure they were safe to use. The practice made arrangements for this to be completed following our inspection and we saw evidence of this.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
- The practice had adequate arrangements in place to respond to emergencies and major incidents. However, they had no supplies of emergency medication used to treat suspected meningitis and had not assessed the associated risks. Following our inspection we saw evidence that the practice purchased this medication.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Staff sought consent from patients in the majority of instances in line with legislation and guidance, however, written consent was not recorded for minor surgery as would be expected. We saw evidence following the inspection that surgery policy had been changed to obtain written consent for minor surgery.
- Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients said they found it easy to make an appointment with the GP and 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 areas where the provider should make improvement are:
- Maintain the new arrangements for checking fire extinguishers and undertake regular fire drills.
- Provide a current building electrical safety certificate and undertake regular testing for non-clinical equipment for electrical safety.
- Obtain and record written patient consent for minor surgery in line with current guidance.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice