Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Alma Sarajlic, also known as Staines Road Surgery on 5 May 2016. The overall rating for the practice was good; however, we identified breaches of regulation in respect of safety, and the practice was rated as requires improvement for the safe domain. We issued a requirement notice in respect of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the practice submitted an action plan, outlining the actions they would take to address the issues identified. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Alma Sarajlic on our website at www.cqc.org.uk.

At the time of the initial inspection, the practice was undergoing a major refurbishment and was temporarily operating from porta cabins and a single room in the main building. We undertook this announced comprehensive inspection on 15 August 2017 to check that the practice had followed their plan and to confirm that they now met the legal requirements, and to check that their newly refurbished premises were compliant with regulations. This report covers our findings in relation to the follow-up inspection.

The practice is now rated as inadequate in respect of safety, and requires improvement in respect of providing effective services and being well led; the practice is rated requires improvement overall.

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

• The practice had some systems, processes and practices to minimise risks to patient safety; however, patients were at risk due to the practice’s failure to ensure that staff had the skills and competence to carry-out their roles.
• Staff demonstrated that they understood their responsibilities in relation to safeguarding children and vulnerable adults and all had received training on safeguarding relevant to their role; however, not all staff had received refresher training within the recommended timeframe.
• The practice was not always able to demonstrate how it ensured that staff were working within their scope of competence.
• There was some evidence of quality improvement; the practice had a programme of regular reviews of their lists of certain patients; however, the practice had not initiated any new clinical audits in the past year.
• The practice’s performance in respect of the delivery of care to patients and patient outcomes was largely comparable with local and national averages; however, the practice’s uptake rate for childhood immunisations was below average.
• Information about services and how to complain was available; however, some staff were unclear about the process. Improvements were made to the quality of care as a result of complaints and concerns.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events; however, whilst learning from incidents was shared with those concerned, the practice did not routinely share information and learning with the wider practice team.
• 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. The practice scored highly for patient satisfaction in all areas. Translation services were available for patients; however, this was not advertised in the patient waiting area.
• 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 a clear leadership structure and staff felt supported by management. The practice proactively sought 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 areas where the provider must make improvement are:

• Ensure that care and treatment is provided in a safe way for service users.
• Ensure that processes are in place to assess, monitor and improve the quality and safety of service, in particular, putting in place a process of clinical audit.

In addition, the provider should:

• Ensure that all staff are clear about the practice’s significant events reporting process and complaints process, and that the learning from all incidents is shared with all staff.
• Improve the uptake of childhood immunisations.
• Advertise the availability of translation services to patients.

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 Alma Sarajlic on 5 May 2016. Overall the practice is rated as good.

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.

• In some areas risks to patients were assessed and well managed; however, there were some areas where the assessment and mitigation of risk was not sufficiently robust, for example, with regards to the Legionella risk and infection prevention and control.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. The practice carried-out clinical audits; however, audit cycles were not always completed and there was limited evidence of quality improvement as a result of audit.
• In most areas staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment; however, there were gaps in training with regards to infection prevention and control.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. We noted that the number carers identified by the practice was very low. We also noted that patients were not aware that they could request a chaperone.
• Information about services and how to complain was available and easy to understand; however, patients were not sign-posted to the Health Service Ombudsman or provided with the contact details for patient advocacy organisations. Improvements were made to the quality of care as a result of complaints and concerns.
• 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.
• At the time of the inspection the practice was undergoing major redevelopment work of its permanent premises, and was therefore temporarily operating from a small section of the main building and from temporary cabins to the rear of the main building. We found that as a temporary arrangement the premises were adequate to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by 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.

The areas where the provider must make improvements are:

Arrangements for patient safety to include: infection control processes including staff training; schedules and records of cleaning being maintained; reviewing the arrangements for the storage of blank prescriptions; a process for checking emergency equipment is in good working order and reviewing fire procedures.

In addition, the areas where the provider should make improvement are:

• They should consider formalising the risk assessment in relation to the Legionella risk at the practice, in order to determine whether a full Legionella assessment is required.
• They should introduce a schedule of clinical audit and ensure that they are completing re-audits of any areas where improvements have been made, in order to assess the effectiveness of the measures introduced.
• They should put a process in place to ensure that all new staff are made aware of the practice’s policies and procedures as part of their induction, and that this is recorded.
• They should ensure that they are making patients aware that they can request a chaperone.
• They should review their action to identify patients who are carers so they can be signposted to relevant services. 
• They should review arrangements for patients to see a male GP.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Dr. Alma Sarajlic's primary medical services were located within premises which were clean and in good repair. The service was professionally managed with support from two receptionists, a practice manager, a clinical manager, a nurse and a health care assistant. The provider demonstrated that effort had been made to deliver the service in line with current professional guidance from the British Medical Association (BMA).

A large number of leaflets were available in the waiting area which provided information about various health conditions, support networks for people with chronic health conditions and loved ones who helped care for them, and additional medical services available in the local area.

We spoke with two people who used the service. Both told us that it was easy to get appointments and that they felt treated with respect by all staff. Neither of the people we spoke with felt any changes or improvements were needed. The complaints procedure was described the practice leaflet, and the provider demonstrated a robust system for managing concerns raised by people who use the service.

There were suitable safeguarding arrangements in place at the service, which ensured that children and vulnerable adults were protected from abuse.

This practice is rated as Good overall. (Previous inspection August 2017 – Requires Improvement).

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 Alma Sarajlic (also known as Staines Road Surgery) on 17 April 2018. This inspection was carried-out to follow up on breaches of regulations identified at the previous inspection.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen; however, with regards to the storage of refrigerated medicines, a complete audit trail of the action taken when the fridge storing these medicines went outside of the recommended temperature was not always kept.
• When safety incidents did happen, the practice learned from them and improved their processes.
• The practice carried-out some reviews of the effectiveness and appropriateness of the care it provided; however, it did not always ensure that these reviews led to systemic improvements.
• During the previous inspection we had concerns about the practice’s failure to assure itself that all staff had received the training they required and remained competent to perform their role. We were informed that the practice was in the process of planning appraisals for the current year, which would include an assessment of competency where appropriate.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a commitment to continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Consider how staff can be effectively appraised to allow the provider to be assured of their ongoing competency, and ensure that the necessary assessments are completed and any identified training needs are met. Review and improve the arrangements in place for monitoring when staff training is due.
• Review the newly implemented Healthcare Assistant protocol to ensure that it accurately reflects the role and the safeguards in place to deliver a safe service.
• Review and improve the current arrangements for the storage of refrigerated medicines and make any necessary changes to ensure the risks identified are mitigated.
• Review and improve the arrangements in place for monitoring uncollected prescriptions.
• Continue to improve the uptake of childhood immunisations.
• Consider how the audit process could be developed to include routine review of clinical decision making, and to ensure systemic improvements are made to the service as a result of the audits undertaken.
• Display information about how to make a complaint in the practice and include contact details for the Parliamentary and Health Service Ombudsman in complaint response letters.

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