Letter from the Chief Inspector of General Practice

We inspected this practice on the 18 November 2014 as part of our comprehensive inspection programme.

We found that the practice had made provision to ensure care for people was safe, caring, responsive, effective and well-led and we have rated the practice as good overall.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Risks to patients were assessed and well managed.

• People’s needs were assessed and care was planned and delivered in line with current legislation and local care pathways. The practice worked proactively to identify those patients at risk of developing long term conditions which were specific to their patient population. They had developed services and worked with local schemes to monitor and improve the health of these patients. Staff had received training appropriate to their roles.

• Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. We also saw that staff treated patients with kindness and respect, and maintained confidentiality.

• Patients said they had difficulty contacting the surgery by telephone but the practice had put systems in place to try to improve this. Urgent appointments were available the same day.

• There was a clear leadership structure and staff felt supported by management. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on.

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

• Administration staff had not had disclosure and barring service (DBS) checks completed although some had received chaperone training and may act as a chaperone on occasion.

• A wide range of information about the practice and services was provided. However, key documents, such as the practice booklet and complaints procedure, were only available in English which did not meet the needs of some of the patient population.

• Verbal concerns that were raised by patients and any actions taken were not always recorded.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our inspection on the 11 November 2013 found the practice did not have robust systems in place which were designed to assess the risk of and prevent and control the spread of health care associated infections. Following the inspection the provider wrote to us and told us they would take action to ensure they were compliant with these essential standards.

At this inspection we found that improvements had been made. The provider had reviewed their policies and procedures and implemented new systems which assessed the risk of and prevented the spread of health care associated infections.

We talked with three people who used the practice. Two people told us they had found it easy to make both non-urgent and urgent appointments. They felt the receptionists were “very good” and the appointments had not been rushed. One person told us it was difficult to make telephone appointments because they had to take their children to school from 8am to 9am when most of the appointments were allocated.

We found that people’s views about the service were acknowledged and responded to. For example in the GP practice survey results 2012 – 2013, people were asked if it was difficult to get through on the telephone, 64 people out of 88 responded that it was not easy to contact the practice by telephone. In response we saw the practice planned to improve the telephone system by adding an extra line.

People who used the service were protected against the risk of abuse. Staff had received training in abuse awareness and protecting children and vulnerable adults. Policies and procedures were available to all staff in relation to safeguarding.

We also found the practice was following their recruitment process and had carried out all the appropriate checks before staff had started work.

We looked at the premises and found the practice did not have robust systems in place which were designed to assess the risk of and prevent and control the spread of health care associated infections.

We carried out an announced comprehensive inspection at The Avicenna Medical Practice on 24 October 2018. The overall rating for the practice was inadequate. The full comprehensive report on the October 2018 inspection can be found by selecting the ‘all reports’ link for The Avicenna Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection, carried out on 16 April 2019 to review actions taken by the provider in response to the warning notices issued by the Care Quality Commission after the October inspection. We issued warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 18 (Staffing).

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• evidence provided to us by the practice

We found that:

• Patient Group Directions (PGDs) were now in place for staff who were not authorised by their profession to administer vaccines unless they are covered by a PGD.
• The provider had reviewed and improved the system for the documentation, discussion, review and manage of significant events.
• All staff had now completed child and adult safeguarding training.
• Mandatory training had been reviewed and completed in line with the practice policy.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care