Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Siraj Shah on 21 February 2017. 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 and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff understood their responsibilities to raise concerns and report incidents and were fully supported to do so.
• Safeguarding vulnerable adults, children and young people was given priority. Staff took a proactive approach to safeguarding, responded appropriately to signs or allegations of abuse and engaged effectively with relevant organisations to implement protection plans.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Patients had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing. Care and treatment was regularly reviewed and updated.
• Data from the Quality and Outcomes Framework showed patient outcomes were below or comparable to the national average. However, The practice did not consistently use the Quality and Outcomes Framework and the data was therefore not reliable.
• The practice used a system of searches, flags and pop up alerts to identify the care and treatment needs of patients with long-term conditions.
• Clinical audits were carried out and these were completed audits which demonstrated quality improvement.
• The practice’s uptake for the cervical screening programme was 65%, which was highlighted as a significant negative variation from the clinical commissioning group (CCG) average of 87% and the national average of 81%. However, the practice had a consistent high level of non-attenders, and provided clear evidence of regular follow ups to engage these patients.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with 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 practice sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

The inspection team consisted of an Inspector and a GP specialist advisor. We spoke with the practice manager, two administrative staff and a practice nurse.

Patients' were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Patients' were protected from the risk of infection because appropriate guidance had been followed.

Patients' were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Patients' were cared for, or supported by, suitably qualified, skilled and experienced staff.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

We spoke with patient's who used the service, staff, nurses and doctors. People told us that they were happy with the service they received. One person told us, "Yes, they sort me out very quickly". Another person told us, "They are very good to us".

We could not locate any risk assessments completed for areas such as manual handling, Control of substances hazardous to health (COSHH), health and fire safety. When we asked the registered manager about this they confirmed that they did not have any in place.

We found that the practice had no clear defined process for staff to follow to report suspicions of abuse, or information about the types and signs of abuse to look out for.

We spoke with one of the staff members regarding their understanding of decontamination procedures in the surgery. The description for the decontamination processes was explained to us and was in line with Decontamination Guidelines.

The provider was not able to show us a clear Environmental Cleaning and Maintenance Policy or domestic cleaning plan.

We noted that the contents of the emergency drugs cabinet were logged, checked and signed off every month to ensure that these drugs had not expired.

Risks associated with accessibility to the prescription scripts in the nurses room had not been adequately addressed by the provider.

There was not an effective recruitment and selection process in place and the provider had employed staff without undertaking appropriate pre-employment checks before staff began work.

Patients and their representatives were not regularly asked for their views about their care and treatment.

The provider told us that they did not have a Quality/Audit policy in place. We found that the service had not completed any audits in relation to quality for example in relation to patient records, management of medicines or infection control.