Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Dr Babar for one area within the key question responsive. We found the practice to be good in providing responsive services. Overall the practice is rated as good.

The practice was previously inspected on 1 November 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection the practice was rated good overall. However, within the key question responsive, areas were identified as requiring improvement because the practice was not meeting requirements at that time.

• They did not show that details of complaints and significant events were discussed in meetings with non clinical staff.
• The provider should further improve, embed and monitor patients satisfaction in the services provided.

The practice provided us with an action plan detailing how they were going to make the requiredimprovements.

The full comprehensive report following the inspection on the 1 November 2016 is available on our website at www.cqc.org.uk/location/1-549549831

The focused desk top review of evidence on 9 May 2017 was to confirm the required actions had been completed and award a new rating in the domain of responsive, if appropriate.

The practice has submitted to CQC, a range of documents which demonstrate they are now meeting requirements

Professor Steve Field CBE FRCP FFPH FRCGP 

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Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Dr IK Babar on 1 November 2016. Overall the practice is rated as good.

The practice had been previously inspected on 2 February 2015. Following that inspection the practice was rated as requires improvement with the following domain ratings:

Responsive – Requires Improvement

Well led – Requires improvement.

Safe – Requires Improvement

Effective – Requires improvement

Caring – Requires Improvement

The practice provided us with an action plan detailing how they were going to make the required improvements.

The inspection on 1 November 2016 was to confirm the required actions had been completed and award a new rating if appropriate.

Following this re-inspection on 1 November 2016, 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 assessed and well managed.
• 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.
• 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.
• 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 practice had a programme of clinical audits which demonstrated quality improvement.
• The practice had a clear consent policy to ensure patient and doctor safety.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Minutes of staff meetings should show details of complaints and significant events that had been discussed with non clinical staff.
• The practice should action the findings of a recent Health and Safety risk assessment.
• The practice should further improve, embed and monitor patient satisfaction in the services provided.

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 IK Babar on 2 February 2015. Overall the practice is rated as requires improvement

Specifically, we found the practice to require improvement for providing safe, effective, and responsive and well led services. It also required improvement for providing services for the population groups as detailed below.

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

• Equipment used by the practice had been tested for its safe use and fire safety tests had been carried out. The premises were clean and tidy on the day of the inspection. Patients we spoke with told us they always found the practice clean and had no concerns about cleanliness or infection control.
• The practice had arrangements in place to manage emergencies and all staff were trained in basic life support.
• The practice nurse held dedicated clinics for chronic disease management and some GP’s held specialist clinics such as diabetes, heart conditions and Chronic Obstructive Pulmonary Disease.
• The practice held annual reviews for patients with a diagnosis of dementia. The practice was currently screening all patients over the age of 75 for dementia.
• The staff we spoke with said they enjoyed their work and felt well supported by the practice manager.
• Monthly educational meetings were held for GPs which provided them with an opportunity to discuss patient care and improve their learning
• A variety of health checks were offered to a range of patient groups including those aged 40 to 75.
• The practice offered a full range of immunisations for children, travel vaccines and flu vaccinations.
• Patients told us they received support from staff following bereavement and they felt safe using the service.
• The practice offers registration to patients who are homeless and members of the traveller community.
• The practice has access to a telephone translation service and most of the GPs and reception staff spoke different languages to support patients whose first language was not English.

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There were areas of practice where the provider needs to make improvements. Importantly, the provider must:

• Ensure the safekeeping of medicines
• Ensure clinical audits of practice are undertaken, including completed clinical audit cycles
• Ensure a record is kept of patients’ consent to treatments.
• Ensure patients know the correct procedure for making a complaint and complaints are investigated and monitored to help identify recurring issues.
• Ensure significant events are completed and recorded to monitor and review the quality and safety of services provided.

In addition the provider should:

• Obtain patients’ views of the service to identify and address any concerns.
• Ensure new patient information is stored securely.
• Ensure clinical supervision is available to nursing staff.
• Ensure patients are involved in making decisions about the care and treatment they receive.
• Ensure access to appointments is improved.
• Ensure all staff are provided with an appraisal of their work and complete training to reflect their role and the needs of the patients using the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We undertook follow up inspection to Dr IK Babar on the 1 May 2014.

We did not speak to people who used the service during this inspection.

We found that since our last inspection the registered provider had taken action to ensure that systems to review and monitor the quality of service patients received was in place.

We found that patient surveys had been sent out and in response to patient feedback in the surveys the practice was currently reviewing the number of baby clinics held each week at the practice. This meant that the registered provider had listened to patient feedback and had taken action to improve the standard and quality of the service provided at the practice.

We found that whilst there had been some improvements in the recruitment process that the practice operated, there was further work which needed to be done before patients were fully protected.

We saw that patients were treated respectfully and given privacy during their visit to the practice. Translation services were available for patients who did not speak English as their first language. Patients were able to make appointments with a doctor of their preferred gender.

We looked at the electronic records of a random selection of patients. The reason for their appointment was documented as well as discussions held with the medical professional, advice given, and tests that had been recommended.

Procedures were in place for the safeguarding of adults and children. Although not all staff had received training, the staff we spoke with knew the action they should take if they suspected a patient or visitor was being abused.

All areas of the practice were visibly clean. The practice had a contract with the Croft Shifa Health Centre who provided services in relation to the prevention and control of infection.

The practice did not have a recruitment policy. Evidence of identity had not been provided for staff members and there was no evidence that references had been provided prior to staff starting work. Some medical professionals at the practice had not had a Criminal Records Bureau (CRB) check carried out.

There was no system in place to assess and monitor the quality of the service. The most recent patient survey had been carried out in January 2012 and no action plan was in place to address less positive results.