Letter from the Chief Inspector of General Practice

We previously carried out three announced comprehensive inspections and a focused inspection at Dr Imran Haq’s practice. Following an inspection in February and March 2015 the practice was rated inadequate overall and placed into special measures. Subsequent inspections in November 2015, February 2016 and July 2016 showed continuous improvement and the practice was rated as good overall in July 2016. The full comprehensive reports for these inspections can be found by selecting the ‘all reports’ link for Dr Imran Haq on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 1 September 2017 to confirm that the improvements made leading to the good rating in July 2016 had been sustained. The overall rating of good has been maintained.

Our key findings were as follows:

• Improvements leading to the good rating in July 2016 had been sustained and the practice continued to make improvements for example, in relation to the quality outcomes framework.
• Patient outcome data was mostly in line with local and national averages. However, performance was lower for childhood immunisations for under two year olds and uptake of bowel screening.
• The practice’s list size had recently increased by approximately 350 patients following the closure of a nearby practice. The practice was in the process of assessing what impact this was having and whether action was needed to increase staffing.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety. These included safeguarding, medicines management and recruitment processes.
• 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 high levels of patient satisfaction with the service. Patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Patients found it easy to make an appointment and access the service. Same day urgent appointments were available if needed. There was continuity of care.
• Information about services and how to complain was available.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure with strong managerial support. Staff felt supported and worked well as a team.
• Future direction and working with other local practices was currently in negotiation to identify areas for improving efficiency.
• The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour.

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

The provider should:

• Review and continue take action to improve the uptake of national screening programmes for bowel cancer and childhood immunisations for under two year olds.

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 Imran Haq’s practice on 22 July 2016. Overall the practice is rated as good.

Dr Haq’s surgery was placed into special measures following an inspection in March 2015. In order to establish if the required improvements had been made we completed a further comprehensive in February 2016. Improvements to the delivery of service were evident, and ongoing, therefore the practice remained in special measures for a further three months.

Following the inspection in February 2016 the practice received an overall rating of requires improvement with an inadequate rating in the effective domain. Two breaches of the Health and Social Care Act 2008 were identified. These breaches related to the regulation 13, safeguarding service users from abuse and improper treatment and regulation 17, good governance. Two requirement notices were issued and the practice subsequently submitted an action plan to CQC on the measures they would take in response to our findings.

At our follow-up inspection on 22 July 2016 we found that the practice had made significant improvement. The two requirement notices we issued following our previous inspection had both been met. The practice is now rated as good overall.

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

• The system for reporting and recording significant events had been reviewed and further developed. Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning from incidents was shared amongst staff.
• Risks to patients were assessed and well managed and all staff we spoke with were familiar with the location of emergency equipment.
• Results from the national patient survey showed that patients rated the practice lower than local and national averages to questions about patient involvement in planning and making decisions about their care and treatment in GP consultations. However, we saw that they had been significant improvements in patient satisfaction in other areas of GP consultations.
• The practice was rated above average for nurse consultations in comparison to both local and national averages. For example, between 95% - 100% of patients stated that the last nurse they saw or spoke to was good at listening, good at treating them with care and concern and good at involving them in decisions about their care.
• The practice was found to be an outlier for QOF (or other national) clinical targets in mental health, hypnotic prescribing (medicines used to help with sleep), cervical screening and hypertension.We saw evidence that practice had worked to address this and had carried out audits which had enabled them to decrease hypnotic prescribing rates. Unpublished data available from the practice for 2015 showed significant improvements in these areas.
• Information about services and how to complain was available with a complaints poster displayed in the waiting area and complaints information was also found in the practice leaflet. No formal written complaints had been received by the practice in the last year. The practice told us that a selection of verbal complaints had been recorded in order to identify trends and themes.
• Patients said they found it easy to make an appointment with a named GP and that 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 were disabled facilities and translation services available.
• The practice sought feedback from staff at practice meetings and appraisals and from patients through practice surveys and the patient participation group (PPG).
• The provider was aware of and had produced a policy that complied with the requirements of the Duty of Candour.

The areas where the provider should make improvements are:

• Continue to review the national patient survey results in order to target the areas below average to further improve patient satisfaction.
• Formalise the sustainability plans to ensure continuity of care and future planning.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 Imran Haq’s practice on 22 February 2016. Overall the practice is rated as requires improvement. This inspection was in response to our previous comprehensive inspection at the practice on 20 February and 31 March 2015 where breaches were found (some of which had also been identified before). This had led to the practice being rated as inadequate and being placed into special measures. Following our previous inspection we issued requirement notices and warning notices to the practice to inform them where improvements were needed. We then carried out a warning notice inspection on 6 November 2015 to ensure that the warning notice breaches were now being met.

The identified breaches found at the previous comprehensive inspection on 20 February and 31 March 2015 related to breaches of regulation under fit and proper persons employed, good governance and safe care and treatment.

At our inspection on 22 February 2016 we found that the practice had improved. The two of the three requirement notices we issued following our previous inspection related to fit and proper persons employed and safe care and treatment had both had been met. The practice was continuing to work on the breach in relation to good governance. A breach under safeguarding patients was also found. The practice is now rated as requires improvement overall (with effective still rated as inadequate).

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

• Significant events had been logged using a reporting form and we saw evidence to indicate that significant events were discussed at meetings.

• Not all clinical staff were familiar with the location of emergency equipment.

• Results from the national patient survey showed that patients rated the practice lower than local and national averages to questions about patient involvement in planning and making decisions about their care and treatment in GP consultations.

• The practice was rated above average for nurse consultations in comparison to both local and national averages. For example, between 97% - 100% of patients stated that the last nurse they saw or spoke to was good at listening, good at treating them with care and concern and good at involving them in decisions about their care.

• The practice was found to be an outlier for QOF (or other national) clinical targets in mental health, hypnotic prescribing (medicines used to help with sleep), cervical screening and hypertension.We saw evidence that practice were working to address this and had carried out some audits which had enabled them to decrease hypnotic prescribing rates.

• Information about services and how to complain was available with a complaints poster displayed in the waiting area and complaints information was also found in the practice leaflet. No formal written complaints had been received by the practice in the last year. The practice told us that a selection of verbal complaints had been recorded in order to identify trends and themes.

• Patients said they found it easy to make an appointment with a named GP and that 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 were disabled facilities and translation services available as well as level access and a bell at the front entrance doors so that wheelchair users were able to request assistance when required.

• The practice sought feedback from staff at practice meetings and appraisals and from patients through practice surveys and the newly established patient participation group (PPG).

• The provider was aware of and had produced a policy that complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Ensure the patient clinical system is effectively used to enhance patient care. For example by maintaining an accurate and complete record in respect of each patient and of the decisions taken in relation to the care and treatment provided.

• All clinical staff must become familiar with the location of emergency equipment and any emergency alerts set up on the clinical system.

• Ensure the safeguard lead fully recognises all potential safeguarding concerns.

In addition the provider should:

• Put systems in place to ensure that the newly-developed policies and processes become embedded so that they continue to be maintained.

• Review the clinical audit schedules and take any other action to ensure further improvement of patient outcomes.

• Proactively review, understand and meet the wider needs of its patients.

• Continue to review the national patient survey results in order to target the areas below average and improve patient satisfaction.

• Consider the ways in which patients with hearing difficulties may be appropriately supported at the practice.

The practice was placed in special measures following the inspection in March 2015. Where insufficient improvements have been made and a rating of inadequate remains for any population group, key question or overall, we would usually take action in line with our enforcement procedure to begin the process of preventing the provider from operating the service. This would lead to cancelling their registration or to varying the terms of their registration. On this occasion, although one rating of inadequate remains, we have extended the special measures period by three months. With the support from consultant practice managers, the CCG and the Royal College of General Practice the provider was able to demonstrate areas of significant improvement.

However there remained areas requiring further development. The three months extension to special measures was given in order to give the provider the opportunity to demonstrate the current improvements are sustained and improvements to care delivery continue to be made. If there is not enough improvement at the end of this period, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. The practice will be kept under review and if needed could be escalated to urgent enforcement action.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an unannounced focused inspection at Dr Imran Haq practice on 6 November 2015.

Following a comprehensive inspection on 31 March 2015, the overall services provided at the practice were rated as inadequate and the practice placed into special measures.

We had issued a warning notice in relation to The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 17: Good Governance.

This was a follow up inspection to look specifically at the areas identified in the warning notice to see if improvements had been made following our previous inspection. We had also received information which prompted us to review the management of controlled drugs.

In addition to this inspection, practices placed in special measures will be inspected again within six months of the report being published. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This may lead to our cancelling their registration or to varying the terms of their registration within six months if they do not improve.

As this inspection was to focus on the warning notice the original rating remains. This will be reviewed at the comprehensive inspection.

The practice had two part time practice managers working at the practice, both on a consultancy basis, to assist practice staff with their policies and procedures and provide advice about the day to day operations of the practice. It was evident that the improvements to meet the warning notice requirements had taken place since their involvement with the practice.

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

• The practice had completed one infection control audit with an overall score of 98%

• The practice demonstrated that appropriate guidance and management of controlled drugs was being followed

• Results from the national GP patient’s survey July 2015 showed improvements from the previous in-house survey and a Patient Participation Group (PPG) had been established.

However, there were also areas of practice where the provider needs to make improvements and these will be followed up at our next inspection to ensure action has been taken. 

Importantly, the provider must:

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Ensure risk assessments relating to fire safety are reviewed and outstanding actions addressed.

In addition the provider should:

• Consider the benefits of having a robust system for managing staff files

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our previous inspection in October 2013 we found that some areas of the practice required improvement. For example the recruitment processes in place were not robust. Following the inspection the provider sent us an action plan giving details of action taken to ensure robust systems and processes were in place.

This visit to the practice was announced. This was to ensure we had the opportunity to speak with the GP and staff working at the practice and review the actions identified in the action plan.

There was a policy in place for the storage of medicines and vaccines. However, this policy was not always being followed in practice

Quality monitoring systems at the practice did not always identify and address areas of the practice requiring improvement. The implementation and monitoring of risk assessments was not robust. The provider was unable to demonstrate that patients were protected against the risk associated with unsafe or unsuitable premises.

There was a policy and process in place to ensure that staff employed at the practice had the necessary checks and qualifications prior to commencing employment.

We visited the surgery to establish that the needs of people using the service were being met. On the day of the inspection we spoke with four staff members, the practice manager, a receptionist, the GP and the practice nurse. We also spoke with nine patients who had arrived for their appointment. All the patients we spoke with were very positive about their experience. One patient said: “Brilliant, I get an appointment the same day. The GP is a real family/community orientated doctor”. Another person said: “He (the GP) is extremely through”.

The surgery did not have appropriate arrangement in place for medical emergencies.

This meant that the surgery did not to ensure the needs of patients would be met during an emergency.

Staff had received training and clinical staff were booked to attend the highest level of safeguarding training. Appropriate guidance was available for staff to follow if abuse was suspected.

We found that safety systems were not fully in place. This meant that patients were not fully protected against the risks of unsafe or unsuitable premises.

We found that there were inadequate recruitment processes in place. This meant that patients were not fully protected from risks of unsuitable people providing care.

The provider did not have a robust system in place for monitoring the quality of service provision. Patients were not encouraged to share their views and highlight areas for improvement at the practice.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Imran Haq also known as Firs Surgery on 20 February and 31 March 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice to be inadequate when providing a safe, effective and well led service. The practice is rated good in providing a caring service and requires improvement in the delivery of responsive care. The issues which led to us rating the service as inadequate apply to all population groups and they are all therefore rated as inadequate.

Our key findings were as follows:

• In spite of there being an outstanding requirement for the provider to have safe recruitment systems in place and assurances received through their action plan the systems in place to ensure safe recruitment processes were in place were not robust.

• We found that the practice was visibly clean. Patients who we spoke with were satisfied with the standards of hygiene at the practice. However, some measures had not been taken to protect patients from risks of unnecessary infections.

• Staff had not received adequate support, appraisals or role specific training to ensure they carried out their roles effectively. The provider failed to monitor staff practices which may impact on patient care.

• Patients told us they were treated with respect and their privacy and dignity were maintained. They informed us they were satisfied with the care they received. They told us they were able to make informed decisions about their care and treatment.

• Clinical risks to patients were not always identified and acted on to protect them against the risks to their health and wellbeing. For example, medicine reviews for patients with long term conditions were not always carried out when they should have been to ensure patients received appropriate medicines. The practice performance on preventative screening was significantly below the Clinical Commissioning Group average.

• Effective systems were in place for reporting safety incidents. However, the practice’s approach to reporting, investigating and acting on significant events was inconsistent and did not allow learning to be shared when things went wrong.

• There were inadequate systems in place to ensure effective governance and as a consequence there were risks to patients which had not been identified, assessed and managed effectively. The lack of governance and effective systems to use feedback from patients and staff affected the provider’s ability to assess, monitor and improve the quality of the service.

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

Importantly, the provider must:

• Have governance systems in place that take into account the views of and feedback from patients, staff and others in effectively using this to help assess and ensure all risks (including clinical risks) to patients, staff and others are identified, assessed and action taken to mitigate against these. Ensure that the system in place monitors and improves the quality of the service.
• Have appropriate arrangements to ensure staff are properly supported. For example, with supervision, appraisals and that their training needs are identified and addressed.
• Ensure there is a robust recruitment system in place to ensure that potential staff are suitable to work with patients. This includes ensuring staff who carry out chaperoning duties have the information or training needed to undertake this role and have either had a Disclosure and Barring Scheme (DBS) check or ensure there is a clear risk assessment in place demonstrating why this is not necessary.
• Ensure clinical risks to patients are identified, assessed and managed by ensuring there is a consistent approach towards recording, investigating and acting on significant events, clinical audits and ensuring they take action to ensure all pre-registration critical clinical information (including from other providers) is summarised and scanned on to patient files without delay.

In addition the provider should:

• Utilise annual patient surveys to identify improvements in service delivery and action them.

• Review and make relevant changes to policies and procedures so that staff had up to date and accurate guidance.

• Strengthen the systems in place for ensuring accurate and up to date records of activity are maintained such as minutes from meetings held with external health professionals, and records of staff training.

• Consider ways to engage with patients in order to develop a Patient Participation Group (PPG).

On the basis of the ratings given to this practice at this inspection, and the concerns identified at the previous inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice