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

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Peel Hall Medical Practice on 21 July 2015. The overall rating for the practice was requires improvement with the key questions of safe and well-led rated as requires improvement. The full comprehensive report on the July 2015 inspection can be found on our website at http://www.cqc.org.uk/location/1-526710208.

This inspection was an announced comprehensive inspection carried out on 14 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 July 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

• At our inspection in July 2015, we found that systems for recording significant events were lacking. At this inspection, we saw that a comprehensive incident reporting form had been introduced and a system for sharing and reviewing events was in place although this system was not always followed or sufficiently documented.
• The practice had systems to reduce risks to patient safety. The system for securely storing and monitoring loose prescriptions in the practice had been improved since our last inspection and a new cleaning record for clinical equipment was in place. At our inspection in July 2015, we found that the system for managing patient safety alerts was insufficient; however, at this inspection we found that this had improved.
• The practice was able to demonstrate safe staff recruitment although there was a lack of some suitable checks for a recent locum GP working in the practice.
• The practice was clean and tidy and an infection prevention and control (IPC) audit had been carried out. However, the practice lacked some policies and procedures for infection prevention and control and there was no record of IPC training for some staff.
• The practice had copies of risk assessments for the premises and all building safety checks were in place although there was evidence of insufficient risk assessment for staff working. Recruitment processes and procedures did not allow for non-clinical staff to be risk-assessed for the role and there was no confidential health questionnaire issued to staff on recruitment.
• The practice had adequate arrangements to respond to emergencies and major incidents although there had been no review of those emergency medicines held by the practice. The practice business continuity plan was not complete.
• At our previous inspection, we found that staff had not been trained to the appropriate level for safeguarding children and vulnerable adults. At this inspection, we saw evidence that clinical staff had trained to the appropriate safeguarding level although records of non-clinical staff training were sometimes lacking. We found that all staff we spoke to had a good knowledge of their responsibilities regarding safeguarding. Meetings with other health professionals for safeguarding discussions were often informal and not minuted.
• Staff were aware of current evidence based guidance. Clinical staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment although records of non-clinical staff training were incomplete. There was no management overview of staff training.
• The practice had introduced a programme of staff appraisal since our inspection in July 2015 and all staff had received an appraisal; however, records of discussion at nurse appraisals were lacking and lacked a personal development plan to guide future training.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. We saw that the system for documenting patient complaints had improved since our last inspection.
• Patients we spoke with told us they liked the practice morning walk-in surgeries with GPs. They understood that this meant that they did not always see the same GP and that they needed to wait sometimes. Patients could also book appointments with a named GP up to two weeks in advance.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a leadership structure and staff felt supported by management. There were policies and procedures in place to govern activity although these were insufficient for some areas of practice service delivery and some needed review. Not all staff we spoke to were able to access the policies when asked.

• There was no overarching governance framework to support the delivery of the strategy and good quality care. Quality improvement was not embedded in the practice; there was no set agenda of quality improvement items for staff meetings.
• The practice encouraged 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.

The area where the provider must make improvement is:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the practice should make improvements are:

• Review the practice process for identifying significant events and follow the significant event procedure to review actions taken as a result of events.
• Consider what medicines are held by the practice for use in medical emergencies.
• Improve the clinical staff appraisal process to document discussion at appraisal and produce staff development plans.
• Improve the overview of training, particularly to demonstrate all staff have undertaken safeguarding training and training relevant to their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Dr Bakhat on the 21 July 2015. Overall the practice is rated as requires improvement. Specifically, we found the practice to require improvement for providing  safe and well led services. It was good for providing an effective caring and responsive service.

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

• The practice had a system in place for reporting, recording and monitoring significant events, incidents and accidents. However, no record was kept of discussions that took place about the analysing of incidents.
• Safeguarding policies and procedures were available for staff to refer to when necessary. Further safeguarding training was planned for a number of clinical and non- clinical staff.
• Information about services and how to complain was available.
• Potential risks to the service were anticipated and planned for in advance.
• Staff were supported with their training and learning development.
• The practice worked with other agencies and professionals to support continuity of care for patients
• Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment.
• Most staff considered there to be an open culture within the practice, and they had the opportunity to raise issues during team meetings.

Importantly the provider must:

• All staff should be provided with the appropriate level of safeguarding training for their role. A record should be kept of meetings held in relation to patient safeguarding concerns.
• Ensure medicines are managed safely including improvements to the process for dealing with medicine alerts and the security of prescriptions.
• Ensure governance systems bring about improvements to the running of the service.

In addition the provider should:

• Improve the way significant events and incidents are recorded and keep a hard copy of this information to demonstrate and support staff learning and improvement of patient outcomes.
• Improve the process for deciding which audits are completed and consider involving the whole clinical staff team in any decisions.
• Improve the process for auditing alerts that come into the practice and consider appointing a member of staff to take responsibility for disseminating these alerts. An audit trail of all alerts received should be kept.
• Provide staff with chaperone training as necessary.
• Establish a cleaning schedule for the equipment used by clinical staff.
• Provide staff with an annual appraisal of their work.
• Improve systems for keeping clinical staff informed about patients’ care needs.
• Provide staff with training on the Mental Capacity Act and patient consent to treatments.
• Improve the documentation kept in relation to the management of complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with seven people who used the service. They all told us that overall they were happy with the service they received. Comments included: “I can’t put them high enough up the scale. They’re wonderful”, “They’ve always been great, sat back and listened. I’ve never felt rushed” and “I can’t thank them enough for their care and attention. All the doctors, the nurses and the reception staff; they’ve been wonderful.”

The practice had single consultation rooms and offered a chaperone service to promote people’s privacy and dignity. People were given information about the services available and this information could be provided in different formats to meet people’s need.

The practice met with other health and social care professionals to ensure people were receiving care and support from appropriate services in order to improve their overall health and wellbeing.

Staff received appropriate training in adult safeguarding and child protection. They were able to identify the possible signs that abuse may be occurring.

The practice undertook a range of audits and participated in the Quality and Outcomes Framework system in order to monitor and assess the quality of the service they provided.

Appropriate pre-employment checks were carried out for new staff.