Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Esmail Esmailji on 19 July 2016. Overall the practice was rated as requires improvement because breaches of regulation relating to the safe and effective provision of services were identified. The full comprehensive report on the 19 July 2016 inspection can be found by selecting the ‘all reports’ link for Dr Esmail Esmailji on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 24 May 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 in July 2016. 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.

Our key findings were as follows:

• The practice had undertaken and implemented an infection control audit for assessing and monitoring risks associated with infection control, and undertaken relevant actions as required.

• The practice had reviewed and established a programme of clinical audits against defined criteria (with re-audit to demonstrate improvement and effective monitoring).

• The practice had implemented an appraisal schedule and undertaken full written appraisals for all staff.

• The practice had assessed, monitored and improved the quality and safety of the services provided in relation to legionella. Legionella is a term for particular bacteria which can contaminate water systems in buildings.

• The practice was working with the clinical commissioning group to establish a patient participation engagement within the practice to ensure feedback is proactively sought.

Additionally, the practice had reviewed how they identified carers in order to provide additional support to patients who are also carers. At the last inspection, the practice had identified 19 patients who were also carers, which was equivalent to 0.7%. At this inspection, the practice had increased their number of carers to 55 patients which was equivalent to 2% of the practice list.

However, there was an area of practice where the provider needs to make improvements.

The provider should:

• Ensure actions taken as a result of infection control audits are clearly recorded when these have been completed.

We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services.

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 of Dr Esmail Esmailji on 19 July 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 generally well managed, however the practice had not completed an infection control audit.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. 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.
• Patients said they found it very 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 and complied with the requirements of the duty of candour.

• The practice provided excellent patient access all urgent appointments were scheduled for the same day and routine appointment could be scheduled within 48 hours.

The areas where the provider must make improvements are:

• Undertake and implement an infection control audit for assessing and monitoring risks associated with infection control, and undertake any relevant actions as required.

• Review and establish a programme of systematic clinical audits against defined criteria (with re-audit to demonstrate change and effective monitoring) and share learning to improve patient outcomes.

• The provider must implement and undertake full written appraisals for all staff.

• Assess, monitor and improve the quality and safety of the services provided in relation to legionella. Legionella is a term for particular bacteria which can contaminate water systems in buildings.

• Establish patient participation engagement within the practice to ensure feedback is proactively sought.

The areas where the provider should make improvement are:

• Review how the practice identifies carers in order to increase the numbers of patients who may require carer support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice