Dr Abdul Naeem Also known as Dog Kennel Lane Surgery

Updated 19 December 2016

Dr Abdul Naeem’s Practice is part of the NHS Sandwell and West Birmingham Clinical Commissioning Group (CCG). CCGs are groups of general practices that work together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services.

Dr Abdul Naeem’s practice is located in a semidetached converted two storey property situated in a residential area, located in the Oldbury area of the West Midlands. All clinical services are provided on the ground floor. The practice list size is approximately 1,850 patients. Patients of various ages are registered and cared for at the practice. Services to patients are provided under a General Medical Services (GMS) contract with NHS England.

Based on data available from Public Health England, the practice has higher levels of deprivation than the national average. It is within the 20% of the most deprived areas nationally.

Practice staff consist of two GPs (one male and one female). At the time of our inspection one of the GPs was on maternity leave and their sessions were being covered by the principal GP who was working nine sessions per week. There are two health care assistants, a practice manager and a team of administrative staff. The practice employs a locum practice nurse who works one session every two weeks.

The practice is open; Monday to Friday 8 am to 6.30 pm. Appointments are available between 9 am and 11 am each morning and from 4pm to 6pm in the afternoon. When the practice is closed services are provided by an out of hours provider which are reached through the NHS 111 telephone service.

The practice was previously inspected by CQC in January 2016. The practice was rated requires improvement overall and was found to be in breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Updated 19 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive follow up inspection at Dr Abdul Naeem’s practice on 25 October 2016. The practice had previously been inspected in January 2016 and was found to be in breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During our inspection in January 2016 we found that the practice did not have effective systems in place to assess, monitor and improve the quality of services provided. The practice was rated as requires improvement for providing services that were effective and well led and was rated requires improvement overall.

Following the inspection in January 2016 the practice sent us an action plan detailing the action they were going to take to improve. We returned to the practice to consider whether improvements had been made in response to the breaches in regulations. We found the practice had addressed the concerns previously raised and had made sufficient improvements. The practice is now 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 generally well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Since our previous inspection there were significant improvements in relation to patient outcomes for those with long term conditions.
• 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 but not displayed. There were few formal complaints and verbal complaints were not recorded.
• Patients said they found it easy to make an appointment with urgent appointments available the same day.
• The practice had made some adaptations to the premises to support those with a disability.
• The premises was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients but had limited engagement with patients through the patient participation group.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Review systems for documenting safety alerts to ensure they have been reviewed and acted on.
• Maintain accurate records for monitoring the cleaning of clinical equipment.
• Ensure immunisation records are maintained for appropriate staff.
• Review the contact list in the business continuity plan to ensure it is accurate and up to date.
• Ensure the window in the health care assistants room is covered when in use to promote privacy for patients.
• In the absence of a hearing loop, review and identify how patients with a hearing impairment may be supported.
• Ensure information is visibly displayed to raise patient awareness of the complaints system and introduce a system for recording verbal complaints so that learning may be gained from them.
• Review and identify ways in which patient involvement in the practice may be improved.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 19 December 2016

The practice is rated as good for the care of people with long-term conditions.

• Patients with a long term condition were invited at least annually to attend a structured review to check their health and medicines needs were being met.
• For those patients with the most complex needs, the GPs worked with relevant health and care professionals to deliver a multidisciplinary package of care.
• Performance for diabetes related indicators (2015/2016) showed the practice had achieved 92.7% of total QOF points which was slightly higher than the CCG average of 88% and national average of 90%.
• The practice provided enhanced services for the management of patients with diabetes on insulin.
• Longer appointments and home visits were available if needed.

Updated 19 December 2016

The practice is rated as good for the care of families, children and young people.

• The practice worked with the health visitors to share information about children living in disadvantaged circumstances and any concerns.
• Immunisation rates were relatively high for all standard childhood immunisations.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. For example, information displayed which recognised the rights of young patients to a confidential service and support for young carers.
• The practice’s uptake for the cervical screening programme was 76%, which was slightly lower than the CCG average of 79% and the national average of 81%.
• Same day appointments were made available for children under 12 years.
• Appointments were available outside of school hours.
• Baby changing facilities and a room for breast feeding was made available on request.
• The midwife operated antenatal clinics from the premises every two weeks.
• Postnatal checks on new mothers and baby checks were undertaken at the practice.

Updated 19 December 2016

The practice is rated as good for the care of older people.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice performed well in relation to patient outcomes The latest nationally reported data available showed the practice was performing well compared to CCG and national averages for outcomes for conditions commonly found amongst older such as diabetes and chronic obstructive pulmonary disease.
• The practice reviewed patients who were at high risk of hospital admission and worked as part of a multi-disciplinary team to support the care of those with complex and end of life care needs.

Updated 19 December 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. This included health checks, weight management and smoking cessation services.
• The practice made use of texting to remind patients of their appointments.
• Although the practice did not provide extended opening hours appointments could be made up to 6pm and telephone consultations were available.

Updated 19 December 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• Nationally reported data for 2015/16 showed 100% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was higher than the CCG and national average of 84%. There was no exception reporting.
• National reported data for 2015/16 showed 100% of patients with poor mental health had comprehensive, agreed care plan documented, in the preceding 12 months which was above to the CCG average 91% and national average 89%. There was no exception reporting.
• The practice told us that they worked closely with consultant psychiatrist to provide support for patients with dementia and carried out advanced care planning for this group of patients.
• Information was displayed in the waiting room about local counselling services available for those with poor mental health.

Updated 19 December 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a registers of patients living in vulnerable circumstances including those with a learning disability and with caring responsibilities.
• The practice had a register for patients who had a learning disability. They were offered an opportunity of an health check.
• The practice offered longer appointments for patients with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice displayed information to patients about how to access various support groups and voluntary organisations.
• The practice identified patients who were carers and provided information about support available, and provided flexibility with appointments, home visits if unable to leave the person they were caring for and flu vaccinations.
• Practice staff told us that they did not have anyone registered with the practice who was of no fixed abode but told us that they would register with the practice address if they did.
• The practice participated with IRIS; a service supporting women to stay safe from domestic violence.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies.