Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Layth Delaimy on 25 January 2017. The overall rating for the practice was good and the practice was rated requires improvement for providing safe services. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr Layth Delaimy on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 11 January 2018 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 on 25 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good and is now rated good for providing safe services.

Our key findings were as follows:

• Infection control was being monitored within the practice and where risks were identified action was taken.
• The temperature of the fridge used for storage of vaccines was monitored and appropriate action taken when concerns arose.
• A risk assessment for lone working had been completed.
• Recruitment checks had been completed for staff employed since our last inspection.

In addition we saw evidence of:

• Information advising patients that chaperones were available was clearly displayed in the waiting area.
• The practice was monitoring management of long term conditions including improvement to the system used for contacting patients about their annual reviews. A healthcare assistant had been trained to help with long term condition management.
• Improvements were made to the quality of care as a result of additionally reviewing informal and verbal complaints and concerns.
• However, there is also one area of practice where the provider needs to make improvements.

The provider should:

• Review polices and protocols to ensure that they are practice specific and reflect current practice.

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 Layth Delaimy on 12 January 2016. The practice was rated as requires improvement for providing safe, effective, responsive, well-led services and good for providing caring services. The overall rating for the practice was requires improvement. The full comprehensive report on the January 2016 inspection can be found by selecting the ‘all reports’ link for Dr Layth Delaimy on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 25 January 2017. Overall the practice is now rated as good, with the area of safe still requiring improvement.

Our key findings were as follows:

• Patients said they found it easy to make an appointment with a GP of their choice and urgent appointments were available the same day.
• 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 managed, with the exception of infection control, medicines management, lone working and recruitment checks.
• 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.
• Patients said they were treated with compassion, dignity and respect.
• Information about services and how to complain was available and easy to understand.
• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice:

The practice demonstrated how they had worked with the North West Surrey clinical commissioning group (CCG) and the South East Coast Ambulance Service to provide a solution to automating shared care records for patients. The practice developed the IT solution and piloted this in house before it was rolled out to the CCG. The information that was shared assisted the ambulance service to improve quality and efficiency of care for patients. We saw evidence that showed this system had reduced the number of patients that required ambulance transport to hospital for treatment by 30% across the CCG. This system has now been adopted by other CCGs in the area covered by the South East Coast Ambulance Service.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure an infection control audit is carried out by a suitably qualified person and address all risks identified, including those noted in this report.
• Ensure that vaccines are stored safely in accordance with manufacturer’s instructions, including monitoring and recording minimum and maximum temperatures of refrigerators and that staff monitoring the temperatures have been given sufficient training to perform this role.
• Carry out a risk assessment for lone working and address any risks identified.
• Ensure recruitment arrangements include all necessary employment checks for all staff.

The provider should:

• Continue to review processes to ensure patients with long term conditions receive the best care.
• Continue to regularly review polices and protocols to ensure that they are practice specific and reflect current practice.
• Ensure that signs are clearly displayed advising patients that chaperones are available.
• Record informal and verbal complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Layth Delaimy on 25 January 2017. The overall rating for the practice was good and the practice was rated requires improvement for providing safe services. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr Layth Delaimy on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 11 January 2018 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 on 25 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good and is now rated good for providing safe services.

Our key findings were as follows:

• Infection control was being monitored within the practice and where risks were identified action was taken.
• The temperature of the fridge used for storage of vaccines was monitored and appropriate action taken when concerns arose.
• A risk assessment for lone working had been completed.
• Recruitment checks had been completed for staff employed since our last inspection.

In addition we saw evidence of:

• Information advising patients that chaperones were available was clearly displayed in the waiting area.
• The practice was monitoring management of long term conditions including improvement to the system used for contacting patients about their annual reviews. A healthcare assistant had been trained to help with long term condition management.
• Improvements were made to the quality of care as a result of additionally reviewing informal and verbal complaints and concerns.
• However, there is also one area of practice where the provider needs to make improvements.

The provider should:

• Review polices and protocols to ensure that they are practice specific and reflect current practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection we spoke with four members of staff. We asked the receptionist to give out our questionnaires to people who attended for their appointments on the day of our inspection visit. We also requested that people were asked if they would like to talk to the inspectors. We received eight completed questionnaires. None of the people who attended the practice on the day of our visit requested to talk to us.

From the results of the patient questionnaire, we saw that patients felt staff at the practice treated them with dignity and respect. They informed us that they always felt safe during their consultations with the medical staff. No concerns were raised by patients in relation to the cleanliness of the practice.

Patients informed us that they felt staff were knowledgeable and informative.

Six patients informed that they knew how to make a complaint.

We found the service was compliant with the five outcomes we looked at.