Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Azim and Partners on 31 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr Azim and Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 June 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. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• The practice appraised all members of staff on an annual basis. New members of staff have three formal reviews within the first six months of employment as well as an annual appraisal.

• All staff had access to training via an online training programme. All staff had completed mandatory training such as basic life support training and fire safety training.

• The practice updated their recruitment policy and all new members of staff had appropriate pre-employment checks in place.

• The practice enhanced their induction programme and all new members of staff had a comprehensive six month induction with support in place.

• The practice had a system in place to ensure patient safety alerts were monitored and acted upon.

• The practice took actions to increase the uptake in cervical screening. For example the practice increased the number of clinicians trained to provide cervical screening from one nurse to three nurses and two GPs. The practice targeted patients whose first language is not English and provided an educational workshop on the importance of participating in cervical screening.

• The practice displayed a health and safety poster in the reception area with appropriate contact information.

• The practice identified 97 carers, more than 1% of the patient population.

• The practice developed a three year business plan to enable management to monitor future development of services within the practice.

• The practice developed a business continuity plan which included a neighbouring practice which can provide temporary space for clinical consultations and emergency contact numbers. All staff had access to the plan.

• The practice developed a mission statement; all staff were included in creating the mission statement. The practice posted the core values in the administration area as a reminder to all staff, the mission statement was on display in the patient waiting area.

At our previous inspection on31 August 2016, we rated the practice as requires improvement for providing safe and effective services as there was gaps in the recruitment and induction process for new staff, the system for managing patient safety alerts did not have a fail-safe mechanism and not all staff were supported with training relevant to their role and annual appraisals. At this inspection we found that the practice had taken action to improve all the areas we identified as required improvement at the inspection in August 2016. Consequently, the practice is now rated as good for providing safe and effective services which means the overall rating of the practice is good.

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 Azim and Partners on 31 August 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• There were a number of areas where risks to patients were not suitably assessed and managed including those relating to: recruitment checks for all staff; mandatory training for all staff; a lack of evidence that all staff had followed a suitable induction programme when starting with the practice; or of all staff receiving an annual appraisal.

• There was no fail-safe system for ensuring that clinical staff reviewed medicines alerts.

• Most patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. A few patients said it was difficult to make an appointment via the phone.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• 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 must make improvements are:

• Ensure that all staff are supported via a programme of annual appraisals.

• Ensure that systems are in place for all staff to undertake and to be kept up to date with mandatory training in line with national guidance and guidelines.
• Ensure the procedure for all staff recruitment includes undertaking all relevant pre-employment checks as specified in Schedule 3 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• Ensure that a suitable system is introduced to manage medicines alerts so that these are reviewed and actioned in a timely manner by all clinical staff.
• Ensure that all staff follow an induction programme when starting with the practice to provide them with the skills and knowledge appropriate to their roles.

In addition the provider should:

• Consider ways to improve uptake of its cervical screening programme for the benefit of female patients.

• Display a Health and Safety poster incorporating appropriate contact information in the reception area so that staff are aware of who to contact in the event of needing to report a health and safety issue.
• Review how patients with caring responsibilities are identified and recorded on the patient record system to ensure information, advice and support is made available to all.
• Prepare a business plan to assist in forming and reviewing its future plans for development of the practice.
• Develop a business continuity plan so that staff are able to contact appropriate sources of assistance in the event of disruption to services to patients.
• Prepare a mission statement so that staff and patients are aware of the practice’ overarching purpose.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice