Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr KM Al-Kaisy’s Practice on 17 May 2016. The overall rating for the practice was requires improvement. The full comprehensive report on 17 May 2016 inspection can be found by selecting the ‘all reports’ link for Dr KM Al-Kaisy Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 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 on 17 May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At our previous inspection on 17 May 2016, we rated the practice as requires improvement for providing safe and effective services. Most systems and processes for monitoring and mitigating risks to patients had improved, but some had gaps such as recruitment checks, fire safety and not all staff who acted as chaperones had a Disclosure and Barring Service (DBS) check. In addition, the practice told us that not all verbal concerns were recorded. At this inspection we found that some of these issues had been addressed, however we found that risks to patients were still not managed effectively in relation to recruitment arrangements, staff training and fire safety. The practice is still rated as requires improvement for providing safe and effective services.

Our key findings were as follows:

• We found that not all staff had completed basic life support (BLS) training as per Resuscitation council guidelines.

• Clinical audits now demonstrated quality improvement.

• All practice procedures and guidance we checked had been recently updated and specific to the practice, for example, the practice had reviewed the Business Continuity Plan in March 2017.

• Appointments with a female GP would be available from May 2017.

• All staff had now completed fire and infection control training.

• The practice did not have an up to date fire risk assessment, however we saw evidence which confirmed that this had been booked to take place in May 2017.

• The practice had not risk assessed staff needing a DBS check to carry out chaperoning duties andwe did not see evidence that pre-employment checks had been completed on staff specific to schedule three regulation.

• The complaints system and processes had been reviewed and the practice told us that verbal complaints were reviewed and discussed during monthly meetings. However, the evidence we reviewed did not confirm this was ongoing, for example, the practice could not provide us with minutes of meeting where these had been discussed for months January through to March 2017.

• Not all staff who acted as chaperones had been DBS checked. The practice had not followed up with the agency when disclosures were not received.

• Staff appraisals had lapsed for all staff members; the practice manager told us that staff appraisals were postponed due to internal employee relation issues. All appraisals were scheduled to take place between May 2017 and July 2017.

The areas where the provider must make improvement are:

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

• Ensure effective systems to assess monitor and mitigate risks to patients such as fire risk assessment and DBS checks.

The areas where the provider should make improvements are:

• Ensure the systems in place to identify the learning needs of staff are current, for example, staff appraisals.

• Review the induction programme to include topics such as safeguarding and information governance.

• Ensure mandatory training namely basic life support is completed in a timely manner and according to current guidelines.

• Strengthen the current system in place so as to ensure that verbal concerns are reviewed and discussed in accordance with practice policy.

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 KM Al-Kaisy Practice on 17 May 2016. Overall, the practice is rated as requires improvement.

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

• The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse. However non-clinical staff had not received training on safeguarding children or vulnerable adults relevant to their role.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and fire safety.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, verbal complaints were not always recorded.
• Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
• The practice had a number of policies and procedures to govern activity, however not all policies were being followed.
• Data showed patient outcomes were comparable to the national average.
• Patients said they were treated with compassion, dignity and respect.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure there are systems in place to monitor and manage risk to patient and staff safety, including fire safety.
• Ensure that there are systems in place to manage staff training for their roles so that staff have the skills and knowledge to deliver effective care.

In addition the provider should:

• Review and update procedures and guidance.
• Ensure there is a programme of continuous clinical and internal audits being used to monitor quality and to make improvements.
• Review patient access to a female GP.
• Review the complaints process and systems.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as requires improvement overall. (Previous inspections May 2016 and 2017 – Requires improvement)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at at Dr Al-Kaisy’s Practice on 23 April and 9 May 2018, to follow up on breaches of regulations identified at our inspection in May 2017. We had to visit the practice over two separate occasions to complete the inspection as a key member of staff was not available on the first visit due to personal reasons.  At our previous inspection in May 2017, we rated the practice requires improvement for providing safe and effective services. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for link for Dr KM Al-Kaisy Practice on our website at www.cqc.org.uk.

At this inspection we found:

• The practice had ineffective systems to manage significant events, safety alerts, COSHH and fire safety.
• Systems to keep people safe and safeguarded from abuse were reflective of best practice.
• 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.
• The practice organised and delivered services to meet patients’ needs, for example, contraceptive services borough wide.
• The practice did not have a mission statement or formalised values and visions.

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

The areas where the provider should make improvements are:

• Review and take steps to improve indicators which are below national averages such as QOF figure for diabetes and childhood immunisation.
• Review the required staffing levels to operate effectively, including reception staff.
• Consider how the practice provide access to a female GP when requested by patients.
• Review and provide clinical staff with the appropriate tool for assessing pain in patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice