The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Zulfikar Moghul Also known as Grove Surgery

Overall: Requires improvement read more about inspection ratings

200-202 Chadwell Heath Ln, Chadwell Heath, Romford, Essex, RM6 4YU (020) 8548 7520

Provided and run by:
Dr Zulfikar Moghul

Important: The provider of this service changed. See new profile

All Inspections

22 September 2022

During an inspection looking at part of the service

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

4 and 9 November 2021

During a routine inspection

We carried out an announced focused inspection at Dr Zulfikar Moghul (Grove Surgery) on 4 and 9 November 2021. Overall, the practice is rated as inadequate.

The ratings for each key question are as follows:-

Safe - Inadequate

Effective – Inadequate

Well-led – Requires Improvement

The provider and location was previously inspected in January 2017, when we rated the service as good overall.

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

This inspection was an announced focused inspection in line with our inspection programme of inspecting practices where there is indication of a change in the quality of care provided. Information obtained from our internal information systems alongside information provided by service users and external stakeholders prompted the inspection of this provider.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A shorter 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 have rated this practice as inadequate overall.

We found that:

  • The provider did not have clear consistent processes for managing risks, issues and performance. For example, medicines management processes related to monitoring high-risk medicines and for people with long-term conditions.
  • There were ineffective processes in place to facilitate ongoing monitoring of safety alerts received by the practice.
  • The provider had limited evidence of quality improvement activities.
  • Monitoring of the work of some clinical staff was not conducted to ensure quality and safety.
  • The location had improved its uptake for cervical screening, but the uptake was still below the recommended 70% uptake.
  • Unqualified staff coded patient records as having patient reviews with no evidence of clinical staff having completed the review.
  • The provider did not have the appropriate authorisations in place for relevant staff to administer medicines.
  • There was co-ordination with other organisations to provide care for patients, but this was not consistent.

The areas where the provider must make improvements:-

  • 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 placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for a key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

5 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Zulfikar Moghul (Grove Surgery) on 5 January 2017. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Some patients said they did not find it easy to make an appointment with a named GP, but urgent appointments were available the same day. The practice was working to improve access.
  • The practice had identified less than one percent of its patients as carers.
  • Results of the national GP patient survey showed that the practice was performing below local and national averages in a number of areas. The practice was aware of this, and had taken action to improve patient satisfaction.
  • Performance for child immunisations was below national averages.
  • 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 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.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • 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 results from the national GP patient survey and continue to work to improve patient satisfaction, including in relation to phone access and waiting time to be seen after arrival for an appointment.

  • Review how carers are identified and recorded on the patient record system to ensure information, advice and support is made available to all.

  • Consider how to improve its child immunisation programme for the benefit of that patient group.

  • Continue to monitor and ensure all medical alerts are brought to the attention of all relevant staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice