Archived: Dr Pervez Sadiq Also known as Hillside House Surgery

We carried out an announced comprehensive inspection at Dr Pervez Sadiq also known as Hillside House Surgery on 15 January 2020 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 16 January 2019.

This inspection looked at the following key questions:

Safe;  Effective;  Responsive; Caring and  Well-led.

At the last inspection in January 2019 we rated the practice as requires improvement for providing responsive and well-led services because:

• Information about how to raise a concern was not readily accessible and the response to patients about the outcome of their complaint investigation lacked detail and the required information.

• The provider did not have oversight of the practice and robust strategies were not in place to give insight into the quality of care and treatment provided so that areas in need of improvement could be identified and managed.

At this inspection we found that the provider had satisfactorily addressed these areas.

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

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• The provider should provide formal policies and procedures in relation to patients accessing online services.
• The provider should introduce a mechanism to prompt checks of professional registration and review the recruitment checks to ensure a health declaration is available for all newly recruited staff including apprentices.
• The provider should take steps to ensure consulting rooms are locked when not in use.
• The provider should introduce formal processes to confirm they have reviewed the prescribing competency of non-medical prescribers.
• The provider should formalise the risk assessment for the single item of medicine not available in the emergency medicines kit and review the contents lists for the doctors-bags and emergency medicines kit so that the lists reflect what is carried.
• The provider should consider formalising the results and changes made for all audits.
• The provider should consider putting systems in place to satisfy themselves that GPs keep their skills for specific procedures up-to-date and confirm that GPs have oversight of individual outcomes for patients when appropriate.
• The provider should consider options to reduce further the risk of private conversation being overheard.
• The provider should review the risk assessment and seek formal assurance that all fixtures and fittings meet best practice guidance.
• The provider should provide staff with information about the Speak-up guardian staff support initiative.

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

We carried out an announced comprehensive inspection at Dr Pervez Sadiq also known as Hillside House Surgery on 16 January 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 14 March 2018.

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

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

We rated the practice as good for providing safe services because:

• The practice had systems and processes to keep patients safe in relation to infection prevention and control, however, not all areas were covered.
• Safeguarding systems were robust and the practice made child protection referrals and participated in multiagency child protection meetings as required.
• Receptionists had been given guidance on identifying deteriorating or acutely unwell patients and were aware of the actions to be taken in respect of those patients. This area could be improved if training included information on how to identify and deal with possible sepsis.
• The practice had appropriate systems in place for the safe management of medicines.
• The practice learnt and made changes when things went wrong, however, systems were not always revised and updated to make sure these changes were sustained or monitored.
• Investigations completed by clinical staff used best practice guidance and the finding were shared with all clinical staff.

We rated the practice as good for providing effective services because:

• The outcomes of care and treatment was monitored. The management of urgent test results was robust and the practice was proactive in ensuring patients received the urgent care and treatment as quickly as possible.
• The practice could show that staff had the skills, knowledge and experience to carry out their roles.
• The practice could show that it always obtained consent to care and treatment.
• Performance data was in line with local and national averages.
• The practice however, were not aware and could not explain the reasons where they had higher than local and national exception reporting rates for some performance data. (Exception reporting allows practices to exclude some eligible patients from indicators and practices should be able to identify the reasons for these exclusions.)

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing responsive services because:

• Complaints were not handled in accordance with the Health and social care act 2008 regulations. At this inspection we found systems and processes for managing complaints were in place however, these were not used effectively. For example, patients were not informed of how to make complaints because there was no information, such as a poster or leaflets about raising concerns in the practice waiting area. This information had to be requested. Complaints we reviewed had not been managed in line with the regulations because records about how the complaints were investigated were incomplete and there was no evidence that the complainant had been responded to appropriately. There was, however a means to record verbal complaints.
• Patients received individualised care and the practice was responsive to different needs in relation to accessing the service. There were no unacceptable barriers to accessing the services.
• Patients said they had timely access to services, the appointment system was easy to use and the information technology available supported their access to services.

This area affected all population groups so we rated all population groups as requires improvement.

We rated the practice as requires improvement for providing well-led services because:

• The practice had made some improvements since our inspection on 14 March 2018, it had appropriately addressed the Requirement Notice in relation to monitoring and reviewing policies and procedures; improving the processes to ensure effective infection prevention and control; ensuring staff training in emergency response was effective and adherence to staff recruitment and induction policies. However, monitoring and reviewing processes were unplanned, inconsistent and did not cover all aspects of the service.
• Leaders could show they had the capacity and skills to deliver high quality, sustainable care, however a written business plan had not been developed.
• The practice had a clear vision which was supported by a credible strategy.
• The practice culture effectively supported high quality sustainable care.
• The practice acted on appropriate and accurate information.
• We saw evidence of systems and processes for learning, continuous improvement and innovation, however learning from serious incidence was not always embedded.
• The practice still needed to improve some processes for managing risks, issues and performance and ensure that these were operating as intended.
• The practice had not developed a comprehensive review plan for the service.

The areas where the provider must make improvements are:

• Ensure that any complaint received is investigated and proportionate action is taken in response to any failure identified by the complaint or investigation and ensure there is an effective system for identifying, receiving, recording, handling, and responding to complaints by persons in relation to caring on of the regulated activity.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review the development of risk registers to include all vulnerable groups of patients.
• Introduce a cleaning schedule which includes areas and equipment that should be periodically deep cleaned.
• Provide administration staff with training in how to recognise and deal with potential sepsis.
• Review how the systems in place to monitor and support improvements at the practice are used.
• Record all investigations in detail so the information available meets best practice guidance.
• Consider how to check whether consent to treatment is correctly obtained at the practice.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice