Dr Ajay Birly Also known as Acorn Medical Centre

This practice is rated as Good overall. (Previous inspection April 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Dr Ajay Birly on 22 February 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice had processes to manage current and future performance, including QOF. However, there was scope for improvement in QOF performance for some indicators, and in particular in reducing high exception reporting.
• Staff involved and treated patients with compassion, kindness, dignity and respect. However, national GP patient survey information we reviewed was mixed when patients were asked about treatment during consultations and their involvement in decisions about their care and treatment.
• Not all patients found the appointment system easy to use and access care when they needed it. However, in 2017 the practice had completed a wide-ranging review of all areas of patient feedback and implemented a comprehensive improvement action plan to address the issues raised, including access to appointments.
• Information about services and how to complain was available and accessible to patients. Improvements were made to the quality of care as a result of complaints and concerns.
• There was a focus on continuous learning and improvement within the practice.

The areas where the provider should make improvements are:

• Complete the review of the practice’s ‘cold chain’ policy initiated after the inspection.
• Review the process for signing of Patient Group Directions (PGDs) to ensure that they are signed by all appropriate staff in all cases.
• Review the practice’s fire evacuation procedure to ensure periodic fire drills are appropriately documented.
• Review action to improve QOF performance in areas where performance has been below CCG and national averages and exception reporting significantly above average.
• Review the system for the identification of carers to ensure all carers have been identified and provided with support.
• Review the implementation of the practice’s patient feedback log and action plan against satisfaction scores from the next national GP Patient survey, particularly those associated with access to services.
• Review the need for an emergency pull cord in the patients’ toilet.
• Review with the PPG and staff the vision set out in the practice’s statement of purpose, with a view to producing a vision and values statement for the benefit of patients and staff.
• Review the practice’s governance systems with a view to introducing formal minutes of all practice meetings to document decisions and action agreed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice