Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr S A Mushtaq & Partners on 5 July 2016. The overall rating for the practice was requires improvement as breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

• Regulation 16 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – receiving and acting on complaints.
• Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – good governance.

From the inspection on 5 July 2016, the practice were told they must:

• Ensure a robust system is implemented to ensure that complaints are managed appropriately.
• Ensure records are maintained securely in relation to governance arrangements, including but not limited to records for complaints received and action taken, infection control audits and personnel files.

In addition, the practice were told they should:

• Develop systems to identify and support more carers in their patient population.
• Continue to monitor the results from the patient survey and establish an action plan for areas which are identified as requiring improvement.

The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Dr S A Mushtaq & Partners on our website at www.cqc.org.uk.

This inspection was a focused follow up carried out on 21 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 5 July 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• Systems had been improved to ensure that a consistent approach was adopted to handling complaints and that appropriate action was taken in response to complaints received. Records of complaints received and action taken were kept securely. We saw that complaints were shared with staff and improvements made to reduce the risk of recurrence.
• The practice had improved governance arrangements to ensure that records were securely maintained and managed appropriately.
• The practice had identified 112 patients as carers (less than 1%) and was actively working to identify and support more carers in its population. The practice had appointed a Carers Champion to work as a key point of contact for carers and to ensure support was available. They regularly liaised with the local charity for carers to provide up to date support and advice to patients.
• The practice regularly monitored national patient survey results and worked towards improving practice performance.

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 S A Mushtaq & Partners on 5 July 2016. We previously inspected the practice in February 2015 and rated them as requiring improvement. Following our inspection on 5 July 2016 overall the practice is rated as requires improvement.

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.
• 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. However, the practice did not demonstrate a robust and consistent approach to managing complaints. We saw that patients were encouraged to give feedback but evidence to support action taken in response to complaints was variable.
• 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.
• 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 provider was aware of and complied with the requirements of the duty of candour.

We saw one area of outstanding practice:

• The practice was classed as a POCT (point of care testing) hub practice within the locality, and alongside six other practices was offering patients additional services not always found within a GP setting. For example, Dr S A Mushtaq & Partners was able to offer D-dimer and deep vein thrombosis (DVT) testing for patients. (D-dimer tests are used to rule out the presence of a blood clot).

The area where the provider must make improvement is:

• Ensure a robust system is implemented to ensure that complaints are managed appropriately.

• Ensure records are maintained securely in relation to governance arrangements, including but not limited to records for complaints received and action taken, infection control audits and personnel files.

The areas where the provider should make improvement is:

• Develop systems to identify and support more carers in their patient population.

• Continue to monitor the results from the patient survey and establish an action plan for areas which are identified as requiring improvement.

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 S A Mushtaq & Partners on 5 July 2016. The overall rating for the practice was requires improvement as breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

• Regulation 16 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – receiving and acting on complaints.
• Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – good governance.

From the inspection on 5 July 2016, the practice were told they must:

• Ensure a robust system is implemented to ensure that complaints are managed appropriately.
• Ensure records are maintained securely in relation to governance arrangements, including but not limited to records for complaints received and action taken, infection control audits and personnel files.

In addition, the practice were told they should:

• Develop systems to identify and support more carers in their patient population.
• Continue to monitor the results from the patient survey and establish an action plan for areas which are identified as requiring improvement.

The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Dr S A Mushtaq & Partners on our website at www.cqc.org.uk.

This inspection was a focused follow up carried out on 21 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 5 July 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• Systems had been improved to ensure that a consistent approach was adopted to handling complaints and that appropriate action was taken in response to complaints received. Records of complaints received and action taken were kept securely. We saw that complaints were shared with staff and improvements made to reduce the risk of recurrence.
• The practice had improved governance arrangements to ensure that records were securely maintained and managed appropriately.
• The practice had identified 112 patients as carers (less than 1%) and was actively working to identify and support more carers in its population. The practice had appointed a Carers Champion to work as a key point of contact for carers and to ensure support was available. They regularly liaised with the local charity for carers to provide up to date support and advice to patients.
• The practice regularly monitored national patient survey results and worked towards improving practice performance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice