Letter from the Chief Inspector of General Practice
In February 2016, during our previous comprehensive inspection of Dr Ajaz Nabi (also known locally as Cippenham surgery), we found issues relating to the effective delivery of healthcare services at this practice. As a result of this inspection, we asked the practice to make further improvements, in order to encourage the uptake of health promotion services offered at this practice. Health promotion is a process which a practice can use to help patients improve their health and wellbeing. Health promotion can involve a range of activities, from encouraging and advertising flu vaccines, to promoting the importance of cancer screening.
During our previous inspection, we also found that the practice did not have a system or a rolling programme for carrying out clinical audits. Furthermore, the practice did not have a clear action plan for patients experiencing poor mental health. The practice’s complaints response did not refer patients to other organisations for example the Ombudsman, if a patient wished to escalate their complaint. Finally at our previous inspection, we also found that the practice needed to review the feedback offered by patients, to help improve services.
As a result of these issues, the practice was previously rated as requiring improvement in effective services, and good for safe, caring, responsive and well led services. This meant that the practice had an overall rating of good.
We carried out a desk based inspection in October 2016 to ensure the practice had made improvements since our last inspection. The practice sent us evidence in the form of letters to patients, patient information leaflets in a number of different languages, and health posters to demonstrate the wide range of improvements they had made since our last visit. The practice also further supplied an audit schedule; this outlined the different audits which were carried out in the practice and how often each audit should take place. Finally the practice was able to provide further supporting evidence, in the form of statistical figures, to demonstrate the impact that changes made to their patient population. We found the practice had made significant improvements since our last inspection in February 2016.
At this inspection we found that:
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The practice had reviewed and updated its bowel cancer screening policy.
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The practice had reviewed and updated its breast cancer screening policy.
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The practice had reviewed and updated its cervical screening policy.
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The practice developed a patient information leaflet explaining the importance of cervical screening.
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Systems were now in place to promote the benefits of cervical, breast and bowel screening.
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The practice had advised us that they had employed an additional member of staff to help monitor the uptake of flu vaccines within the practice.
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The practice had made changes to their website; this included a link to the NHS choices flu webpage for more information.
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The practice developed an audit schedule, outlining the different audits and when each would take place.
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Systems were now in place to monitor and improve services through the use of a clear programme of audits.
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The practice was able to demonstrate the impact of improvements to patient uptake of health promotion services.
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The practice was able to demonstrate evidence of action taken to improve the outcomes for patients experiencing poor mental health.
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The practice had reviewed and updated their complaints policy and procedures. This ensured that within response to complaints, patients were given the necessary information of the complainant’s right to escalate the complaint to the Ombudsman if dissatisfied with the response.
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The practice was able to demonstrate evidence that patient feedback was taken into account regarding practice issues.
Following this desk based inspection we rated the practice as good for providing effective services. The overall rating for the practice remains good. This report should be read in conjunction with the full inspection report of 3 February 2016. A copy of the full inspection report can be found at www.cqc.org.uk.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice