Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Touseef Safdars practice, Central Clinic, on 14 January 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment

Regulation 11 HSCA (RA) Regulations 2014 Need for consent

Regulation 17 HSCA (RA) Regulations 2014 Good governance

We undertook a focused inspection on 2 February 2016 to check that they had followed their plan and to confirm that they now met legal requirements. 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 Touseef Safdar on our website at www.cqc.org.uk.

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

• The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse. Staff were aware of the process and their responsibilities to raise and report concerns, incidents and near misses. We saw that significant events were regularly discussed with staff during practice meetings.

• Staff assessed needs and delivered care in line with current evidence based guidance. A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. Results were circulated and discussed in the practice.

• The practice worked with other service providers to meet patient’s needs and manage those of patients with complex needs.

• The practice had arrangements in place to respond to emergencies and major incidents.

• Staff files demonstrated that appropriate recruitment checks had been undertaken prior to employment.

• There were some arrangements for identifying and recording and managing risks, issues and implementing mitigating actions. The risk assessments for fire and legionella contained actions for completion however there were no timeframes or action owners listed on the action plans.

• The management team encouraged a culture of openness and honesty and staff at all levels were actively encouraged to raise concerns. The practice also sought feedback from staff through an annual staff survey, staff said they felt supported and part of a close team.

The areas where the provider should make improvement are:

• Keep records to support that risks associated with premises and infection control are adequately managed and to reflect the cleaning of the environment.

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 of Dr Touseef Safdars practice, Central Clinic, on 14 January 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment

Regulation 11 HSCA (RA) Regulations 2014 Need for consent

Regulation 17 HSCA (RA) Regulations 2014 Good governance

We undertook a focused inspection on 2 February 2016 to check that they had followed their plan and to confirm that they now met legal requirements. 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 Touseef Safdar on our website at www.cqc.org.uk.

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

• The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse. Staff were aware of the process and their responsibilities to raise and report concerns, incidents and near misses. We saw that significant events were regularly discussed with staff during practice meetings.

• Staff assessed needs and delivered care in line with current evidence based guidance. A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. Results were circulated and discussed in the practice.

• The practice worked with other service providers to meet patient’s needs and manage those of patients with complex needs.

• The practice had arrangements in place to respond to emergencies and major incidents.

• Staff files demonstrated that appropriate recruitment checks had been undertaken prior to employment.

• There were some arrangements for identifying and recording and managing risks, issues and implementing mitigating actions. The risk assessments for fire and legionella contained actions for completion however there were no timeframes or action owners listed on the action plans.

• The management team encouraged a culture of openness and honesty and staff at all levels were actively encouraged to raise concerns. The practice also sought feedback from staff through an annual staff survey, staff said they felt supported and part of a close team.

The areas where the provider should make improvement are:

• Keep records to support that risks associated with premises and infection control are adequately managed and to reflect the cleaning of the environment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our last inspection in February 2014, we found that patients were not adequately protected from the risk of abuse because the provider had taken some reasonable steps to identify the possibility of abuse and prevent abuse from happening. We also found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service. We set compliance actions and told the provider to improve.

The purpose of this inspection was to see if improvements had been made since our last inspection in February 2014. We gave the provider short notice of our inspection so that any disruption to patient's care and treatment were minimised. During the inspection we spoke with four members of staff, this included the practice manager, the lead GP (who was also the provider), the practice nurse and a receptionist.

We saw that the provider had made some changes to improve the service and to improve the quality of the care. However, more assessments were required so that the provider could be assured that this was being delivered.

On the day of our inspection we spoke with six patients and five members of staff. One patient said, “The nurse is nice and the reception staff are always polite." Most of the patients we spoke with said they were unable to obtain appointments at a time to suit their needs. However, all the patients we spoke with said they felt the quality of care they received was good.

We saw that patients were treated with dignity and respect. One patient told us, “The staff are well versed in discretion." We saw that patients experienced care and treatment that met their needs.

Patients told us and we saw that care was delivered in a clean environment. Staff required training in safeguarding of vulnerable adults but were aware of whom to report concerns to.

Improvements were required to the quality monitoring systems to assess and monitor the quality of service that patients received. Improvements in patient engagement and management of risks were required.