Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Syed Masroor Imam on 24 September 2015. Overall, we rated the practice as good. However, the practice was rated as requires improvement for providing well led services. In particular, we found that the arrangements for reception staffing, health and safety and fire assessments, infection control, the treatment of homeless patients and arrangement to ensure the long-term sustainability of the practice through the development and delivery of business plans and plans for improvement should be reviewed.

In November 2016 we undertook a focused inspection, where we asked the practice to send us information to evidence of the improvements they had made. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Syed Masroor Imam on our website at www.cqc.org.uk.

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

• The practice had reviewed the staffing arrangements for the reception area; they had appointed two additional members of staff to ensure that the practice was able to meet the needs of patients at all times.

• The practice completed a fire assessment; however, they had not completed a health and safety assessment.
• The practice had developed their infection prevention, control arrangements, a recent infection control audit had been completed, and staff had undertaken appropriate training. We also saw the practice had updated the infection control policy and this was now in line with current guidance.

• The practice had reviewed arrangements for seeing and treating homeless patients. The practice now provided care and treatment for homeless patients and directed them towards a service that provided housing support and advice.

• The practice had taken steps to ensure the long-term sustainability of the practice through the development and delivery of business plans and plans for improvement. However, the business plan was not well enough developed to ensure sustainability.

The area where the provider should make improvements are:

• Review the arrangements to support sustainability at the practice in the longer term through the development and delivery of effective business plans and plans for improvement.
• Complete a health and safety risk assessment of the 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 Syed Masroor Imam on 24 September 2015. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients and staff were assessed and well managed, with the exception of those relating to health and safety.
• Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
• Results from the National GP Patient Survey showed patients were generally happy with how they were treated and that this was with compassion, dignity and respect. The practice was above local and national averages for its satisfaction scores on consultations with nurses and in line with or in some cases below local and national averages for GPs. The lower than average results for the GPs reflected some of the patient feedback we received on the day.
• Information about services and how to complain was available and easy to understand, although the practice had not received any formal complaints within the last 12 months.
• Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait longer for non-urgent appointments with the female locum GP.
• The practice had a number of policies and procedures to govern activity, however some of these required review in order to make them specific to the practice. The practice held regular governance meetings and issues were discussed at staff and multidisciplinary team meetings.
• There was a limited approach to obtaining the views of patients and other stakeholders. The practice did not have a patient participation group (PPG).
• The practice’s vision and values were not well developed, and there was no strategy or work plan in place. The practice manager demonstrated their desire to lead, learn and improve the practice.

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

The areas where the provider should make improvements are:

• Review and formalise the arrangements in place for staffing in the reception area to ensure they can meet the needs of patients at all times.
• Ensure that health and safety risk assessments, fire training and fire risk assessments are completed as soon as possible and in line with the dates the practice had already arranged for these.
• Continue to fully develop and implement infection control policies and procedures to reflect the requirements as stated in the Department of Health’s Code of Practice on the prevention and control of infections.
• Ensure the arrangements in place for seeing and treating homeless patients reflect the latest guidance.
• Ensure the sustainability of the practice in the longer term through the development and delivery of business plans and plans for improvement.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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 Syed Masroor Imam’s practice on 26 and 28 January 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe and effective services and being well led. It was also inadequate for providing services for the following population groups: Older people; People with long-term conditions; Families, children and young people; Working age people (including those recently retired and students); People whose circumstances may make them vulnerable; People experiencing poor mental health (including people with dementia). Improvements were also required for providing caring and responsive services.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, appropriate recruitment checks on staff had not been made prior to their employment and actions identified to address concerns with infection control had not been taken.
• The arrangements for the recording and storage of blank prescription forms were not robust or secure. There was no rationale to support which emergency medicines were kept within the practice.
• Staff were not clear or directly involved with reporting incidents, near misses and concerns and there was little evidence of learning and communication with staff.
• Staff were not appropriately supported in relation to their responsibilities by means of receiving appropriate training and appraisal.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, there was no system to review medicines for patients who persistently missed their medication reviews and prescriptions for high risk medicines were issued without the patient’s blood test results being checked. This meant patients could continue to access medicines that may be inappropriate or dangerous for them.
• Staff were not aware of the Mental Capacity Act 2005 and their duties in fulfilling it. Nurses did not understand the key parts of the legislation and were unable to describe how they implemented it in their practice. They also demonstrated a lack of understanding of consent issues for children and young people. Staff could not demonstrate an understanding of Gillick competencies.
• Patients were mostly positive about their interactions with staff and said they were treated with compassion and dignity. The National GP Patient Survey results published in January 2015 were better for the nurses than the GPs at the practice.
• Urgent appointments were usually available on the day they were requested.
• The practice had no clear leadership structure, insufficient leadership capacity and very little or no formal governance arrangements. Incidents, near misses, complaints and concerns were not reviewed on a regular basis and any learning from them was not shared widely with staff.

The areas where the provider must make improvements are:

• Take action to ensure effective infection control systems are in place.
• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision. This includes ensuring audits of practice are undertaken, including completed clinical audit cycles. Also, staff must have appropriate policies and guidance to carry out their roles in a safe and effective manner. Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements required within the practice.
• Ensure recruitment arrangements include all necessary employment checks for all staff, including criminal record checks.
• Take action to ensure blank prescription forms are handled safely, including on receipt and on storage and put in place a rationale to support which emergency medicines are held within the practice.
• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines and use these when assessing patient’s needs and when planning and delivering their treatment.
• Ensure staff are appropriately supported in relation to their responsibilities by means of receiving appropriate training and appraisal.
• Put suitable arrangements in place for obtaining, and acting in accordance with, the consent of young patients.

The area where the provider should make improvements is:

• Improve processes for the recording, investigation into and learning from comments and complaints.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice