Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Moujaes and Dr Mannan ‘The Surgery’ on 21 January 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.
• 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 generally 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 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.

  We saw one area of outstanding practice:

• The practice had identified and allocated responsibilities to six members of practice staff for the care coordination and monitoring of specific patient population groups.The individual staff members were known as practice champions and their responsibilities included working with individual patients and liaising with other practice staff or external agencies to ensure patients received care and support appropriate to their needs.

The areas where the provider should make improvement are:

• Implement a system to gain assurance notifiable safety alerts distributed within the practice have been read and action has been taken when appropriate.

• Take action to improve significant event records to ensure they support and demonstrate practice learning.

• Ensure the division of responsibility is clearly defined for individuals allocated lead roles for infection prevention and control.

• Implement a system to monitor and review the validity of patient group directions used within the practice.

• Assess the risks associated to the storage of clinical waste and consider the robustness of the assessment of risks associated to legionella.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice