- GP practice
Archived: Al-Shifa Medical Centre
Important:
The provider of this service changed. See new profile
All Inspections
9 May 2018
During a routine inspection
This practice is rated as Good overall. (Previous inspection 1 December 2015 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Al Shifa Surgery on 9 May 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
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.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- Safety systems were comprehensive and actions were taken to prevent incidents and risks to patients. We noted that portable acceptance testing and fire risk assessments required updating and some recruitment information was not present.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines, however we noted some patient notes had not been fully coded.
- Clinicians had access to appropriate information to deliver safe care and treatment.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported they were able to access care when they needed it. Patient feedback on the care and treatment delivered by all staff was overwhelmingly positive.
- There was a strong focus on continuous learning and improvement at all levels of the organisation
We saw one areas of outstanding practice:
- The practice operated a “safe surgery” principle in partnership with “Doctors of the world”. This aimed to offer healthcare and treatment to anyone regardless of their immigration status, race, gender, sexuality or other characteristic. Staff had received training on specific barriers faced by vulnerable groups and how to mitigate these barriers and provided access to care for patients who otherwise may have been fearful.
The areas where the provider should make improvements are:
- Document recruitment information more fully.
- Improve process for comprehensively coding patient notes.
- Improve processes for ensuring portable appliance testing and fire risk assessments are completed in a timely manner.
- Improve the system/process for monitoring higher risk medicines.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
19 July 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
This is a focused desk top review of evidence supplied by Al-Shifa Medical Centre, for two areas within the key question safe.
We found the practice to be good in providing safe services.
Overall, the practice is rated as good.
The practice was inspected on 1 December 2015. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, within the key question safe, two areas were identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 12 Safe care and treatment and Regulation 19 Fit and proper persons employed HSCA (RA) Regulations 2014
At the inspection in December 2015 we found that; a control of substances hazardous to health (COSHH) risk assessment was in place for Hystofreezer which is used in the practice but other cleaning products did not have a risk assessment in place. ( Hystofreezer is a product for treating warts and benign skin lesions using the local application of intense cold to destroy unwanted tissue).
At the inspection in December 2015 we did not see evidence that the practice had carried out safe recruitment checks for all staff. This included; a review of employment history, professional references, professional registration and DBS checks. Reception staff confirmed that on occasion they undertook the role of chaperone but had not received specific training for this role.
The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 12 Safe care and treatment and Regulation 19 Fit and proper persons employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
1 December 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Al-Shifa Medical Centre on 1 December 2015. Overall, the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- 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, with the exception of those relating to recruitment checks and some aspects of infection control practices.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However, there were some gaps in staff training.
- The practice was proactive in monitoring and improving its performance. This included monitoring medicine prescribing costs and unplanned admissions to A&E.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Patients were complimentary about the staff at the practice.
- Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. Telephone consultations were also available.
- Information about services and how to complain was available and easy to understand.
- The practice had facilities and equipment to treat patients and meet their needs.
- There was an awareness of where the practice needed to improve the services it provided.
The areas where the provider should make improvement are:
Importantly the provider must:
- Ensure recruitment arrangements include all the required pre-employment checks for all staff.
- Improve infection control procedures to ensure cleaning procedures, cleaning equipment and storage minimise any potential risk of the spread of infection. All products used for cleaning require a control of substances hazardous to health (COSHH) risk assessment to be in place.
In addition the provider should:
- Ensure there is an auditable system for monitoring the recording of the receipt of electronic prescription paper and the serial numbers on blank hand written prescription pads held in storage and maintain a record of their allocation to each GP.
- Ensure records that monitor the expiry dates of medicines held by the practice, include the name of the medicine and the amount of stock held on the premises.
- Ensure staff receive training relevant to their role and responsibilities including chaperone and infection control training and understanding the importance of the cold chain when storing medicines in the refrigerator.
- Ensure a planned programme of clinical and internal audits is established to enable the practice to monitor quality consistently and to make improvements as required quickly.
- Record a business plan with priorities and strategies to provide focus and clarity on the development of the service and allow the whole staff team to contribute to the development of the practice
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice