This practice is rated as Good overall. (Previous rating 12 October 2017 – Good)

We carried out an announced comprehensive inspection at Dr Shabir Ahmad Malik on 12 October 2017. The overall rating for the practice was good, with requires improvement for safe. The full comprehensive report on the October 2017 inspection can be found by selecting the ‘all reports’ link for Dr Shabir Ahmad Malik on our website at www.cqc.org.uk.

The key question at this inspection is rated as:

Are services safe? – Good

We carried out an announced focused inspection at Dr Shabir Ahmad Malik on 10 October 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 12 October 2017. We inspected the key question safe as this area related to the breach of regulation.

This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

• The practice had evidence to confirm the immunisation status of applicable clinical and non-clinical staff in relation to other immunisations (other than hepatitis B) recommended by the Health and Safety at Work Act 1974.
• The practice had a system to securely store blank prescription forms and monitor their use.
• The practice had backup temperature data loggers in both medicine and vaccine refrigerators.
• The practice had acted on the recommended improvements following a fire risk assessment.
• The practice could now evidence they had medical defence indemnity for professional negligence claims or allegations of malpractice for a specific clinical staff member.
• We viewed the practice’s unverified cervical screening data, which showed that the practice was on track to deliver this programme to eligible patients.
• Verbal complaints were documented.
• The practice had identified 1% of their patient population as carers.
• The practice had a good awareness of their patients with hearing loss and offered adjustments to support those patients access care in the preferred way for that patient.
• There was a monitoring schedule in place to ensure that the alarm in the patient toilet was functioning correctly.
• There was an ongoing review process in place for all policy documents, this was to ensure that they were updated and so they reflected current effective dates and future review dates.

Professor Steve Field CBE FRCP FFPH FRCGPChief 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 Shabir Ahmad Malik on 12 October 2017. 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 a system in place for reporting and recording significant events. Lessons learnt were shared to make sure action was taken to improve safety in the practice.
• Staff were aware of current evidence based guidance.
• 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.

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect.
• The practice had aims and plans to deliver high quality care and promote good outcomes for patients. Staff were knowledgeable about the aims and plans and their responsibilities in relation to it. However arrangements to monitor and improve quality and identify risk needed strengthening. For example systems and processes to ensure there were effective systems for infection control, fire safety, medicine management and employment checks.

• Clinical staff had been checked for their immunisation status related Hepatitis B. However at the time of our inspection the practice was unable to confirm the immunisation status of applicable clinical and non clinical staff in relation to other immunisations recommended by the Health and Safety at Work Act 1974.

• At the time of our inspection we did not see evidence of a system to securely store blank prescription forms and the associated system to monitor their use.

• At the time of our inspection the backup temperature data logger was not in use in the vaccine refrigerator.
• A fire risk assessment had recommended improvements to the means employed within the practice to give warning of fire and limiting the spread of fire. Both these recommendations had a target completion date of June 2017. At the time of our inspection we did not see evidence that the recommendations had been assessed for implementation or implemented.
• At the time of our inspection the practice could not confirm that medical defence indemnity for professional negligence claims or allegations of malpractice was available for a particular a clinical staff member.
• Patients we spoke with said they found it easy to make an appointment with a 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 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 areas where the provider must make improvement are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please refer to the requirement notice section at the end of the report for more detail).

The areas where the provider should make improvement are:

• Continue to monitor the Quality and Outcome Framework (QOF) exception reporting to ensure all eligible patients receive the national clinical screening programmes.
• Continue to document verbal complaints and include these as part of the overall complaints review.
• Continue to identify and support carers.
• Consider implementing further measures to help the hard of hearing, including the installation of a hearing loop.
• Continue to monitor the recently installed pull cord system in the disabled toilet.
• Review all policy documents so they reflect current effective dates and future review dates.

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 Shabir Ahmad Malik on 09 July 2015. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed and measures put in place to reduce the risks to patients and staff.
• Improvements were required in relation to managing medicines alerts from the Medicines and Healthcare products Regulatory Agency.
• Some staff undertaking chaperone duties had not received a disclosure and barring service check, there was an absence of a risk assessment and they were unsure where to stand during an observation of an examination.
• The practice did not have oxygen or a defibrillator readily available to respond to medical emergencies.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• 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 easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• 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. Team meetings were infrequent and there was a lack of evidence that reflected that staff were aware of issues affecting the practice, including discussion about the learning from safety incidents and complaints.

• The systems in place to identify risks to patients were not robust.

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

Importantly the provider must;

• Review the medical emergency equipment stored at the practice to ensure that staff can respond to a medical emergency.
• Undertake disclosure and barring service checks for staff carrying out chaperone duties or carry out a risk assessment as to why they are not necessary. Ensure staff have received suitable guidance in relation to chaperone duties to ensure patients are safe.
• Implement a robust system for managing alerts from the Medicines and Healthcare products Regulatory Agency.

Importantly the provider should;

• Ensure relevant clinical and non-clinical staff have a working knowledge of the Mental Capacity Act 2005 and Gillick competence in relation to providing consent for care and treatment.
• Review the procedure for checking that emergency medicines do not expire.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice