This practice is rated as Good overall. (Previous rating 08/2017 – Requires improvement)

We carried out an announced comprehensive inspection at Dr Naz Asghar on 10 August 2017. The overall rating for the practice was requires improvement. The service remained in special measures following an initial inspection on 2 August 2016. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures. The full comprehensive reports on the August 2017 and August 2016 inspections can be found by selecting the ‘all reports’ link for Dr Naz Asghar on our website at .

This inspection was an announced comprehensive inspection carried out on 15 May 2018 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 10 August 2017. 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.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

Our key findings were as follows:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• During the August 2017 inspection we found the practice were not maintaining the newly introduced cleaning schedule for clinical equipment, the business continuity plan did not contain emergency contact telephone numbers, and some clinical staff were not aware of the location of an emergency alert button. At this inspection we found the clinical equipment cleaning schedule had been completed as required, the business continuity plan had been updated with emergency contact numbers, and clinical staff were aware of how to raise the alarm in an emergency.
• During the August 2017 inspection we found the practice had failed to assure themselves that the healthcare assistant (HCA) had the skills and knowledge to deliver effective care and treatment, and there were no formal protocols to determine when the HCA should refer a patient for review by a clinician. At this inspection the practice could demonstrate that the HCA had the knowledge and skills to carry out their clinical duties, and there were detailed protocols in line with their role.
• 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.
• During the August 2017 inspection we found patients were not routinely provided with a copy of their care plan, clinical audits showed limited evidence of systemic change, and exception reporting from the Quality and Outcomes Framework (QOF) 2016/17 remained higher than local and national averages. At this inspection we saw evidence that patients were provided a copy of their care plan, clinical audits demonstrated systemic change and improved clinical outcomes for patients, and unverified practice data for 2017/18 showed exception reporting had been reduced.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Feedback from patients and comment cards showed patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to improve uptake rates for cervical and bowel cancer screening.
• Review and take appropriate action in improving access to nursing appointments outside of school hours.

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

Please refer to the detailed report and the evidence tables for further information

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Naz Asghar, also known as the Welcome Practice on 2 August 2016. The overall rating for the practice was Inadequate and the practice was placed into special measures. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr Naz Asghar on our website at www.cqc.org.uk.

We undertook this announced comprehensive inspection on 10 August 2017 to check that the practice had made improvements in order to meet the legal requirements in relation to the breach of regulations 12 (Safe care and treatment), 18 (Staffing) and 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This report covers our findings in relation to those requirements.

Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• The practice had systems in place to minimise risks to patient safety; however, there was a lack of formal protocols in place to ensure that the Healthcare Assistant worked within their scope of competence.
• During the initial inspection in August 2016 we found that the practice’s arrangements to monitor the performance of the practice, including those relating to clinical audit, were insufficient. At this re-inspection we found that the practice had addressed several issues relating to the practice’s performance and that this was being monitored; however, there were some areas where improvements were still required, particularly in relation to their exception reporting rate.

• During the previous inspection we found that not all members of staff were aware of their responsibility to inform the GP of safety incidents, and that when incidents were reported, the practice did not undertake a thorough analysis to establish what had happened and what lessons could be learned. When we re-inspected we found that processes had been put in place to ensure clear and consistent recording of incidents, and that all staff were aware of the processes and their responsibilities.
• During the previous inspection we found that the practice had failed to complete background checks during the recruitment of some staff, and that not all staff had received an appraisal. When we re-inspected we found that background checks had been completed for all staff recruited following the first inspection, and that all staff had received an appraisal.
• At our previous inspection in August 2016 we found that the practice did not have adequate arrangements in place to mitigate risks, including those relating to their ability to respond to medical emergencies. When we re-inspected we found that these issues had been addressed.
• During the previous inspection we found that the practice had insufficient arrangements in place in order to identify patients with caring responsibilities. When we re-inspected we found that these arrangements had improved and the practice had increased the number of patients identified as having caring responsibilities by over 50%.
• During the previous inspection we found that there was a lack of management capacity, which had resulted in a lack of effective governance processes. When we re-inspected we found that a Practice Manager had been appointed and that processes were in place to ensure that staff were supported.
• Care planning was in place for patients who needed additional support; however, patients were not routinely provided with a copy of their care plan and there was a lack of focus on improving clinical outcomes.

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

Importantly, the provider must:

• Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
• Assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity.

In addition the provider should:

• Maintain the newly introduced cleaning schedule for clinical equipment.
• Record emergency contact telephone numbers within the business continuity plan.
• Make all staff aware of the location of emergency alert buttons.
• Consider whether it is appropriate to provide patients with a copy of their care plan.

This practice will remain in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the service 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 announced comprehensive inspection at Dr Naz Asghar also known as the Welcome Practice on 2 August 2016. Overall, the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing a safe and effective service and being well led. It was also inadequate for providing services for; older people, people with long-term conditions, families, children and young people, working age people, people whose circumstances make them vulnerable and people experiencing poor mental health. It was requires improvement for providing a caring service and good for providing a responsive service. Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, staff were not clear about reporting incidents, near misses and concerns. Reviews and investigations were not thorough. Appropriate recruitment checks on staff had not been undertaken prior to their employment.

• Not all risks to patients were assessments well managed.

• There was no induction programme for non-clinical staff and there was no evidence they had been given information on reporting significant events, fire safety and health and safety.

• Data showed patient outcomes were low compared to the local and national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.

• Patients said they were involved in their care and decisions about their treatment.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

• Introduce clear and effective processes for reporting, recording, acting on and learning from significant events, incidents and near misses.

• Ensure that appropriate risk assessments are in place for; fire safety, health and safety and electrical equipment.

• Ensure there is a defibrillator available at the practice or a risk assessment to indicate the risks of not having one have been assessed.

• Provide staff with appropriate training and appraisals to carry out their roles in a safe and effective manner that are reflective of the requirements of the practice.

• Ensure that DBS checks are undertaken as part of the recruitment process for all staff employed at the practice or a risk assessment to indicate the risks of not having one have been assessed.

The areas where the provider should make improvement are:

• Update arrangements in place to ensure that patients with caring responsibilities are identified, so their needs are identified and can be met.

• Provide patients with long-term conditions with person centred care, such as, improving the care provided to patients with asthma and review the care and treatment provided to patients with mental health problems, dementia and diabetes.

• Update policies and processes to improve screening uptake for cervical cytology.
• Improve arrangements so that all equipment used at the practice is calibrated and tested at regular intervals.
• Update the process for recording discussions during all internal meetings.

• Revise the leadership structure and ensure there is leadership capacity to deliver all the required improvements.

• Implement a programme of quality improvement such as clinical audits to improve outcomes for patients.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. 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 will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

During our inspection we spoke with five patients who used the service, the Principal GP, practice administrator, two receptionists, a practice nurse and a health care assistant.

Patients told us they could get appointments without difficulty. One patient told us that they had been registered with the practice for over 20 years. Another patient said, “I cannot complain, they are always flexible here and we see the same doctor always”.

Patients told us they felt respected and listened to by staff.

We viewed summarised feedback from a patient satisfaction survey, which showed that the majority of patients using the practice were happy with the care they received from the practice.

Staff we spoke with told us that they were supported by the GP to develop their role fully.

Comments from staff included, “the GP has an open door policy”, “we are always supported” and “we have worked here for many years and would not do so if we were not supported”.

Patients were protected from the risk of abuse because staff had completed relevant training and knew how to raise safeguarding concerns.

The patients we spoke with told us that they knew how to make a complaint but had never needed to.

We found that the practice had good systems in place to manage their records. Patients personal information was well protected.