Dr Abdul Naeem Also known as Dog Kennel Lane Surgery

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