Archived: Dr Zulfikar Moghul Also known as Grove Surgery

Updated 17 November 2022

Grove Surgery is based in Romford, Essex at:

200-202 Chadwell Heath Lane

Romford

RM6 4YU

The provider is registered with CQC to deliver the following Regulated Activities:-

• Diagnostic and screening procedures
• Maternity and midwifery services
• Treatment of disease, disorder or injury

The practice is situated within the Redbridge Clinical Commissioning Group (CCG) and delivers Primary Medical Services (PMS) to a patient population of about 9,600. This is part of a contract held with NHS England.

The practice is part of a wider network of the local GP Primary Care Network (PCN). This PCN is made up of eight GP practices within this geographical area.

Information published by Public Health England shows that deprivation within the practice population group is in the sixth lowest decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others.

There is one male GP provider who is currently supported by a team of three salaried GPs who provide clinical care at the practice. Two clinical pharmacists work approximately four sessions a week. There is a practice nurse and one healthcare assistant who work varied sessions per week. The clinical staff are supported by a team of part-time reception staff and a practice manager. The local primary care network provides practice access to one clinical pharmacist who works at the practice one day per week.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were a combination of telephone and face-to-face consultations.

The practice opening hours are as follows: -

• 8.00am to 8.00pm Monday to Thursday
• 8.00am to 6.30pm Friday

Extended access and Out of Hours services is provided by the local GP Hub network, where late evening and weekend appointments are available.

Updated 17 November 2022

We carried out an announced focused inspection at Dr Zulfikar Moghul (known as Grove Surgery) on 22 September 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are as follows:-

Safe - Good

Effective – Requires Improvement

Well-led – Requires Improvement

Following our previous inspection on 4 and 9 November 2021, the practice was rated inadequate overall and for key questions safe and effective. Key question well-led was rated as required improvement. As a result of the inspection in November 2021, the provider was placed in special measures.

At the last inspection we rated the practice as inadequate for providing safe and effective services because:

• The provider did not have systems in place to ensure that safe care and treated was being provided.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Zulfikar Moghul on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulation from the last inspection and in keeping with our regulatory framework to re-inspect practices placed in special measures.

Our inspection on the 22 September focused on the key questions of safe, effective and well-led, which were inspected at the November 2021 inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider in advance of the site visit.
• A site visit.

Our findings

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 found that:

• The provider had embedded policies and procedures in place to assist in the management of services provided at the practice.
• The provider did not have clear consistent processes for managing risks, issues and performance, with particular reference to monitoring of clinical staff.
• There were effective processes in place to facilitate ongoing monitoring of safety alerts received by the practice.
• The provider had systems in place to review and act effectively upon significant events that occurred at the practice.
• The provider had evidence of quality improvement and clinical audit activity.
• The location had improved its uptake for childhood immunisations, with the practice achieving the recommended WHO uptake figure.
• The provider had put in place appropriate authorisations in place for relevant staff to administer medicines.
• The National Patient Survey achievement scores for the provider was lower than local and national averages for the second year running.

We found two breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective care systems and process to ensure good governance in accordance with the fundamental standards of care.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services