This practice is rated as Good overall. (Previous inspection April 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Dr Ajay Birly on 22 February 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice had processes to manage current and future performance, including QOF. However, there was scope for improvement in QOF performance for some indicators, and in particular in reducing high exception reporting.
• Staff involved and treated patients with compassion, kindness, dignity and respect. However, national GP patient survey information we reviewed was mixed when patients were asked about treatment during consultations and their involvement in decisions about their care and treatment.
• Not all patients found the appointment system easy to use and access care when they needed it. However, in 2017 the practice had completed a wide-ranging review of all areas of patient feedback and implemented a comprehensive improvement action plan to address the issues raised, including access to appointments.
• Information about services and how to complain was available and accessible to patients. Improvements were made to the quality of care as a result of complaints and concerns.
• There was a focus on continuous learning and improvement within the practice.

The areas where the provider should make improvements are:

• Complete the review of the practice’s ‘cold chain’ policy initiated after the inspection.
• Review the process for signing of Patient Group Directions (PGDs) to ensure that they are signed by all appropriate staff in all cases.
• Review the practice’s fire evacuation procedure to ensure periodic fire drills are appropriately documented.
• Review action to improve QOF performance in areas where performance has been below CCG and national averages and exception reporting significantly above average.
• Review the system for the identification of carers to ensure all carers have been identified and provided with support.
• Review the implementation of the practice’s patient feedback log and action plan against satisfaction scores from the next national GP Patient survey, particularly those associated with access to services.
• Review the need for an emergency pull cord in the patients’ toilet.
• Review with the PPG and staff the vision set out in the practice’s statement of purpose, with a view to producing a vision and values statement for the benefit of patients and staff.
• Review the practice’s governance systems with a view to introducing formal minutes of all practice meetings to document decisions and action agreed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Ajay Birly on 24 April 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that 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.

However there were also areas of practice where the provider needs to make improvements. The practice should:

• Take action to improve eligible patient uptake of the flu vaccination
• Review the palliative care list to ensure records are accurately coded

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Dr Ajay Birly is registered as an individual GP provider. The practiceprovides NHS primary care services to patients in the Hillingdon area through a General Medical Services contract. The practice currently has approximately 5900 patients on its list.

We carried out an announced inspection of the service on 28 August 2014. The team, led by a CQC inspector, included a GP, a former practice manager and a second CQC inspector. We spoke with six patients attending the practice on the day of the inspection and collected 30 comment cards which patients had completed about the service in the days running up to the inspection.

The practice had systems in place to manage risks associated with medicines management, staff recruitment, child protection and adult safeguarding and medical emergencies. Practice procedures on infection control and information governance required improvement. Staff were recruited safely but staff involved in chaperoning patients had not had DBS checks. There were mechanisms to investigate and learn from incidents and complaints. Patients’ needs were assessed and treatment and referral patterns were in line with current guidelines.

Staff participated in collaborative clinical audits and external peer group meetings and used performance information, particularly from the Quality and Outcomes Framework to improve.

Most patients we spoke with were happy with the service they received at the practice. They said they were involved in decisions about their treatment and most staff were sensitive. We observed that reception staff greeted patients in a polite and friendly manner.

The practice was responsive to the needs of its patients. It provided services tailored to particular patient groups, extended opening hours and provided different ways for patients to access the service, including a recently introduced online booking system.

Patients were able to access appointments when they needed them although some patients told us they had difficulty booking an appointment with the same doctor which affected their experience of the service. The practice promoted health and prevention of illness.

The service was well-led in some respects but some areas needed improvement. There were governance arrangements in place and an open reporting culture. However, we found some confusion over roles and responsibilities for example in relation to infection control. The practice responded to complaints and had placed a suggestion box in the waiting room. However it did not otherwiseactively engage with patients and the public. The practice did not have its own website or a patient participation group.

The practice provided services for specific patient groups and some outstanding practice for patients with substance misuse problems and also patients with a history of violence in general practice settings. The practice demonstrated good links and collaboration with other agencies and professionals.

The practice was in breach of regulations related to:

• Care and welfare of patients
• Cleanliness and infection control
• Requirements relating to workers
• Assessing and monitoring the quality of care

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.