Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at the Practice of Dr J A Mir on 19 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 19 September 2016 inspection can be found by selecting the ‘all reports’ link Practice of Dr J A Mir on our website at www.cqc.org.uk.

This inspection was an announced follow-up comprehensive inspection and was carried out on 9 August 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However there were gaps in some of the recording of the events and associated learning.

• The practice had clearly defined and embedded systems to minimise risks to patient safety, but systems did not always ensure good governance.

• 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.

• 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.

• 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 clear leadership structure in place.

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

Importantly, the provider must:

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

• Ensure that accurate, complete and contemporaneous records are maintained securely in respect of each service user. In particular around the recording of significant events and the review of correspondence.

• Ensure staff received regular performance reviews

In addition the provider should:

• Keep its protocol to follow-up on medical alerts such as the Medicines and Healthcare products Regulatory Agency (MHRA) under review to ensure it is effective.

• Keep a formal record of all practice meetings.

• Carry out an annual review of patients with a learning disability.

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 J A Mir on 19 September 2016. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• On the whole, patients 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 the management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

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

Importantly, the provider must:

• Develop a formalised system to act upon medicines and equipment alerts issued by external agencies, for example from the Medicines and Healthcare products Regulatory Agency (MHRA).

• Staff must assess patients’ needs and deliver care in line with current evidence based guidance and improve the way they share and discuss changes to guidance.

In addition the provider should:

• Risk assess the need for emergency medicines within doctors’ bags when they attendhome visits.

• Implement a recorded and formal system of sharing updates in best practice guidelines with the staff team.

• Take steps to identify fridge plugs so that they avoid being turned off accidentally.

• Ensure all clinical staff are up-to-date and familiar with the relevant requirements relating to patient consent.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice