Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Momosir Ali on 22 February 2016. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Dr Momosir Ali on our website at www.cqc.org.uk.

At our previous inspection in February 2016 we rated the practice as ‘good’ overall but as ‘requires improvement’ for safety as we identified three breaches of regulation. This was because improvements were needed to; the staff recruitment procedures, to staff training and to make information about the complaints process available to patients.

This inspection visit was carried out on 3 March 2017 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches. This report covers our findings in relation to that and additional improvements made since our last inspection.

The findings of this inspection were that the provider had taken action to meet the requirements of the last inspection and the service is now rated as ‘good’ for providing safe services. Our key findings were as follows:

• Pre-employment checks for new staff were carried out in line with requirements.

• Staff had been provided with the training they required for their roles and responsibilities. This included the provision of training, since our last inspection, in topics such as: health and safety, fire safety, infection control, safeguarding and the Mental Capacity Act 2015 and Deprivation of Liberty Safeguards (DoLS).

• Information about how to make a complaint was readily available for patients to access.

We also found that the provider had made a number of improvements to the service in response to recommendations we made at our last inspection. These included;

• A process had been introduced to share the learning from significant events. This included significant events being discussed at regular staff meetings.

• A system had been introduced to account for and securely store blank prescriptions.

• Action had been taken to ensure that all Patient Group Directions (written directives for the administration of medicines to a pre-defined group of patients without them having to see a prescriber directly) had been appropriately authorised by a GP.

• A supply of oxygen had been obtained for supporting patients in a medical emergency.

• All referrals to secondary care were now made electronically thereby reducing the margin for error in the referrals process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Momosir Ali on 22nd February 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. The practice had a system in place to report significant events. Staff understood and fulfilled their responsibilities to raise concerns. However there was no formal system to discuss and share findings with the team which limited learning from all events.

• Some aspects of managing safety needed further review. The systems in place for monitoring prescription pads needed to be reviewed to show a clear audit trail of how they were stored and issued. Patient group directives had not been signed by the lead clinicians and have their clinical overview.

• The practice did not have oxygen available to use in emergencies. There was no risk assessment in place to support this decision.

• Staff files lacked evidence of necessary recruitment checks.

• Some records for patient referrals to other services had been completed by hand. This increased the risk of errors in passing on relevant information for referrals.

• Risks to patients were assessed and well managed to safeguard vulnerable patients. However some staff needed training in safeguarding, relevant to their role.

• Staff had the skills, knowledge and experience to deliver effective care and treatment. However some staff needed updated training such as: health and safety, fire safety, infection control and the Mental Capacity Act 2015 and Deprivation of Liberty Safeguards (DoLs.) Staff retention at the practice was good offering stability and continuity of care to patients.
• Patients were positive about the practice and the staff team. They said they were treated with dignity and respect and felt involved in decisions about their treatment.
• Information about services and how to complain was available but patients had to ask for this information from reception. Verbal concerns were not documented and reviewed in line with the complaints procedure.
• Patients were positive about accessing appointments with a named GP and continuity of care.
• The practice had good facilities and was well equipped to treat patients and meet their needs. The management of health and safety within the building was well managed by the practice.
• Staff felt supported by management.

The areas where the provider must make improvement are:

• Take action to ensure its recruitment policy, procedures and arrangements are improved to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held.

• Ensure updated training is provided for all staff including:

  health and safety, fire safety, infection control, safeguarding and the Mental Capacity Act 2015 and Deprivation of Liberty Safeguards (DoLs.)

• Review access and availability of the complaints procedure and review ways of capturing verbal complaints and suggestions from patients.

The areas where the provider should make improvement are:

• Ensure all significant events are formally reviewed and shared with staff to promote learning.

• Review the auditing system for storage of blank prescription pads and the clinical overview of the PGD’s.

• Review with all staff how children at risk are monitored within the practice.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with eight patients as part of our inspection. They spoke positively about the practice and commented that they were happy with the care they received. Comments included, “It’s an excellent service. I can get an appointment easily”, “The GP has really looked after me,” and “I am very satisfied, the staff are very welcoming."

Records showed patients with conditions such as diabetes, asthma and heart disease were regularly seen and their condition monitored by the practice nurse. Patients we spoke with confirmed this was their experience.

The service did not have a separate policy or set of procedures to support vulnerable adults. The Practice Manager confirmed this was being developed and would be available in January 2014. We saw a draft version of this policy. The Practice Manager confirmed a training session was being arranged for staff in January 2014 as part of the implementation of the new policy.

We saw the 12 week induction programme for a member of staff of who recently joined the practice. It included a training needs analysis and meetings with the manager to help confirm they were able to carry out the role.

The practice had systems to seek and act upon feedback from patients using the service, including a patient participation group (PPG). We spoke with a member of the PPG who told us the group had been involved in developing the practice website and the annual patient survey.