This practice is rated as Good overall. (Previous inspection 11/2014 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Z Ahmad & Partners on 10 April 2018. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice displayed a good understanding of the duty of candour.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Some areas of practice performance were below local and national averages. However, the practice had identified the reasons for this and developed comprehensive action plans to make improvements.
• The practice referred patients to expert patient programmes to help them manage their conditions. For example, patients with type 2 diabetes were referred to the DESMOND programme. (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed. Patient education for people with diabetes.)
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The facilities and premises were appropriate for the services delivered. At both the main practice and the practices branch site, the consultation and treatment rooms were on the ground floor and access enabled toilets were available.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice worked to secure and keep services local for patients. For example, they started a long-acting reversible contraceptive (LARC) service after negotiating with the Luton Borough Council to secure funding.

The areas where the provider should make improvements are:

• Complete an action plan to address the areas in need of improvement found in the infection prevention and control (IPC) audit.
• Implement the identified actions to make improvements to the quality and outcomes framework (QOF) monitoring of patients.
• Consider formal training for reception staff to help them identify ‘red flag’ sepsis symptoms.
• Review patient satisfaction in response to the practice opening hours.
• Consider ways to further identify and support patients who are also carers.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We visited Gardenia Practice on the 19 November 2014 and carried out a comprehensive inspection.

The overall rating for this practice is good.

The practice had a branch surgery at Marsh Farm Practice, but this was not inspected.

Our key findings were as follows:

• Patients reported that doctors and the nurse were caring and thorough. The felt they were treated with kindness, dignity and respect.

• There were systems in place to provide a safe, responsive, caring and well-run service although some improvements were required to demonstrate effective care was being delivered.

• The practice had engaged well with patients and had an active patient participation group who represented the views of the practice population.

• The practice demonstrated it had an open and honest culture with systems in place to ensure that they learnt from when things went wrong.

The practice had recently undergone management changes with a change of leadership and a new practice manager. They demonstrated that they had a vision for the practice and were starting to develop plans in how they would achieve their vision, but this was in its early stages. Therefore, the practice should continue to develop and implement this, which would enable them to improve outcomes.

Whilst the overall rating was good, there were some areas which required improvement. The practice should address the following:

• Continue the work they have started to improve their approach to disease management and the development of more robust systems in this area, specifically regarding management of long term conditions.

• Expand the business continuity plan to included detail of how they would access doctors and nurses in an emergency.

• Ensure that a fire drill is carried out as soon as possible and that there is a system in place to ensure they are carried out at regular intervals thereafter.
• Ensure that actions from the fire risk assessment are completed and documented.

• Appraisals should be completed with all staff when appraisal training has been undertaken by the practice manager and a schedule of appraisals should be produced to ensure this continues.

• Ensure that all risks are managed, monitored and appropriate mitigating actions taken.

• Produce a clear strategic development plan to demonstrate how the vision is to be achieved and provide clear direction to staff in order to improve effectiveness.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice