This practice is rated as requires improvement overall. (Previous rating June 2016 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Beheshti’s Practice on 16 July 2018. This inspection was carried under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service.

At this inspection we found:

• The practice had systems to manage most risks, however we found improvement was required in relation to infection control, high-risk medicines, fire safety and COSHH.
• 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.
• The practice did not have adequate arrangements for monitoring uncollected prescriptions.
• Recently published GP patient survey data showed that all staff involved in treating patients did so with compassion, kindness, dignity and respect.
• Patients reported that they found it difficult to access treatment and care.
• Complaints received by the practice were properly investigated, however the practice did not provide written responses for all written complaints received.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Take action to immediately address concerns patients have reported in relation to accessing treatment and care.
• Review and improve how complaints are responded to and consider doing so in line with underpinning standard operating procedure.
• Take action to improve underperforming areas such as childhood immunisations and diabetes.
• Take further action to continually improve low scores as highlighted in the national GP patient survey.
• Review how patients with caring responsibilities are identified so as to ensure they receive the appropriate support.

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 Beheshti on 29 June 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.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patient satisfaction around access to the service was lower than local and national averages.
• 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.
• Patients said they found it difficult to make an appointment with a named GP and to access the practice by telephone.
• 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 and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

• Review and improve the system for managing patients with long term conditions.

• Review and improve access to the practice by telephone.

• Review audit systems in relation to the monitoring of prescription pads in accordance with national NHS guidelines.

• Take action to ensure there is an active Patient Participation Group in the practice.

• Review arrangements for translation services.

• Review procedures for carrying out and recording fire drills.

• To review how patients with caring responsibilities are identified and recorded on the patient record system to ensure information, advice and support is made available to them.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice