The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Touseef Safdar

Overall: Inadequate read more about inspection ratings

The Surgery, Dudley, West Midlands, DY2 7BX (01384) 253616

Provided and run by:
Dr Touseef Safdar

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

All Inspections

7 and 26 July 2022

During a routine inspection

We carried out an announced focused inspection at Dr Touseef Safdar on 7 and 26 July 2022. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Caring – Requires Improvement

Responsive - Requires Improvement

Well-led - Inadequate

The practice was inspected in June 2021 and was rated Inadequate overall. We carried out an unannounced inspection in September 2021 due to information of concern. This was an unrated inspection and we issued a warning notice for a breach of regulation. We carried out an inspection in October 2021 to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in the requirement notice and warning notice we issued to the provider in relation to Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance. An unannounced inspection was carried out in December 2021 due to information of concern and further enforcement action was taken.

Overall, the practice remains rated as Inadequate.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to re-rate the practice and follow up previous breaches of regulation from previous inspections.

How we carried out the inspection

We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of inspection was necessary and proportionate. At this inspection we followed up on areas of concern using our focused inspection methodology.

This included:

  • A site visit.
  • Conducting staff interviews.
  • Completing clinical searches on the practice’s patient records system.
  • Requesting evidence from the provider.

We found that:

  • There were gaps in systems to assess, monitor and manage risks to patient safety, including safeguarding and long term conditions.
  • The practice did not have reliable systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients with long term conditions.
  • Staff did not always have the information they needed to deliver safe care and treatment.
  • There was no systematic structured approach with effective clinical oversight of patient information including clinical data.
  • The practice was unable to demonstrate that it consistently acted on safety alerts.
  • Staff did not always work effectively together and with other organisations to deliver effective care and treatment.
  • Staff were not consistent and proactive in helping patients to live healthier lives.
  • The practice did not have fully embedded assurance systems and had not proactively identified and managed risks. Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • Staff did not always treat patients with kindness, respect and compassion. Feedback from patients was negative about the way staff treated them.
  • Services did not always meet patients’ needs.
  • People were not able to access care and treatment in a timely way.
  • There was a lack of leadership oversight and the absence of comprehensive systems and processes to monitor the quality and effectiveness of the service and the care provided.
  • There was no formal system in place to assess and monitor the governance arrangements.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.

This service was placed in special measures in August 2021. The provider submitted an application to voluntarily cancel their registration as a provider with CQC.

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

21 December 2021

During an inspection looking at part of the service

We carried out an unannounced focused inspection at Dr Touseef Safdar on 21 December 2021 due to concerns around the leadership, governance and management of the practice. This inspection was not rated.

The practice was inspected in June 2021 and was rated Inadequate overall. We carried out an unannounced inspection in September 2021 due to information of concern. This was an unrated inspection and enforcement action was undertaken against the provider. We carried out a further inspection in October 2021 to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in the requirement notice and warning notice we issued to the provider in relation to Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance. Further enforcement action was taken in October 2021.

Overall, the practice remains rated as Inadequate.

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

Why we carried out this inspection

This inspection was a focused inspection in response to concerning information around the governance and leadership of the practice.

How we carried out the inspection

We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of inspection was necessary and proportionate. At this inspection we followed up on areas of concern using our focused inspection methodology.

This included:

  • A site visit.
  • Conducting staff interviews.
  • Completing clinical searches on the practice’s patient records system.
  • Requesting evidence from the provider.

We found that:

  • There were gaps in systems to assess, monitor and manage risks to patient safety, including safeguarding and long term conditions.
  • The practice did not have reliable systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients with long term conditions.
  • Staff did not always have the information they needed to deliver safe care and treatment.
  • There was no systematic structured approach with effective clinical oversight of patient information including clinical data.
  • The practice was unable to demonstrate it consistently acted on safety alerts.
  • The practice did not have formalised systems in place to ensure staff worked within the limits of their competency or to review their performance.
  • The practice did not have fully embedded assurance systems and had not proactively identified and managed risks.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • There was a lack of leadership oversight and the absence of comprehensive systems and processes to monitor the quality and effectiveness of the service and the care provided.
  • There was no formal system in place to assess and monitor the governance arrangements in place.

We found two breaches of regulations. The provider must:

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

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

15 October 2021

During an inspection looking at part of the service

We carried out an announced inspection at Dr Touseef Safdar on 13 and 15 October 2021. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in the requirement notice and warning notice we issued to the provider in relation to Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance.

At the last inspection in June 2021 we rated the practice as Inadequate overall. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the June 2021 inspection report.

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

Why we carried out this inspection

This inspection was a review of information undertaking a site visit inspection to follow up on compliance with a requirement notice in respect of breaches of regulation 12 (safe care and treatment) and a warning notice for regulation 17 (good governance).

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 short 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 not rated this practice as the rating remains unchanged until we have completed a further inspection incorporating all relevant key questions.

However we found that:

Action had been taken to address the areas of concern set out in the requirement notice for Regulation 12, safe care and treatment.

Actions had been taken to address some of the areas of the breaches identified in the warning notice and it was evident that work had taken place and improvements had been made. However, we continued to find some issues and some required actions which were ongoing and not yet fully completed or embedded. These related to the warning notice for regulation 17 (good governance).

We found a continued breach of regulation. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found breaches of regulations, we found the provider should:

  • Review safeguarding registers and ensure these are appropriately coded in patient records.

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

14 and 23 September 2021

During an inspection looking at part of the service

We carried out an unannounced focused inspection at Dr Touseef Safdar on 14 and 23 September 2021. This inspection was not rated.

The practice was last inspected in June 2021 and was rated Inadequate overall. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Touseef Safdar on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection in response to concerning information we received. This included following up on:

  • Concerns regarding patients’ difficulties in obtaining routine and emergency appointments with a GP and/or nurse.
  • Key questions within Safe, Effective and Well Led domains related to the concerns received.

How we carried out the inspection

We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of inspection was necessary and proportionate. At this inspection we followed up on areas of concern using our focused inspection methodology.

This included:

  • A site visit.
  • Conducting staff interviews.
  • 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.

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 practice had not provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients did not always receive effective care and treatment that met their needs.
  • Patients were not always able to access care and treatment in a timely way.
  • Complaints were not appropriately investigated or used to improve the quality of care provided at the practice.
  • The practice culture did not effectively support high quality sustainable care.
  • The practice overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, incidents, concerns and performance.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way to service users.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
  • Send CQC a written report setting out what governance arrangements are in place and any plans to make improvements.

The areas where the provider should make improvements are:

  • Check that all staff have completed safeguarding training appropriate to their role.

Following this inspection enforcement action was taken against this provider to impose conditions on their registration for Regulation 12, Safe care and treatment, Regulation 16 Receiving and acting on complaints and Regulation 17 Good governance. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted. 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.

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

9 and 11 June 2021

During a routine inspection

We carried out an announced inspection at Dr Touseef Safdar Surgery on 9 and 11 June 2021. Overall, the practice is rated as inadequate.

The ratings for each key question are as follows:

Safe - Requires improvement

Effective - Inadequate

Caring - Good

Responsive - Requires improvement

Well-led - Inadequate

Following our previous inspection on 17 December 2019, the practice was rated Requires Improvement overall and for all key questions of safe, effective and caring and good for responsive and well-led services.

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

Why we carried out this inspection

This was a comprehensive inspection to follow up on the previous ratings. Whilst we found no breaches following our last inspection, we also reviewed the areas where the previous inspection identified that the provider should make an improvement, these were:

  • Develop an effective system to risk assess, record and monitor the immunisation status of staff members in line with best practice.
  • Continue work to increase the uptake for cervical, breast and bowel screening.
  • Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
  • Continue work to improve performance and outcomes relating to diabetes.
  • Review procedures in place to demonstrate improved outcomes for patients where satisfaction levels are still low.
  • Continue work to identify and support carers registered in the practice.
  • Complete sepsis training for all staff in the practice.
  • Continue with steps to engage with a patient participation group.

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 short 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 and inadequate for all population groups.

We rated the practice as inadequate for providing effective and well-led services because:

  • Long term conditions outcomes, asthma reviews, chronic obstructive pulmonary disease (COPD) and hypertension reviews were below local and national targets.
  • The practice’s childhood immunisation uptake rates were below the World Health Organisation (WHO) targets for three out of five indicators and there had been a decline in outcomes since our last inspection. The practice had seen improvements in some of their immunisation outcomes, however this was unvalidated data at the time of our inspection.
  • The practice had seen a slight improvement in their cervical screening rates since the last inspection in December 2019, however the actions they had taken to improve had not yet been fully effective and uptake remained significantly below the Public Health England coverage target.
  • Mental health indicators were below the local and national averages. Although the practice had demonstrated improvements in their personalised care adjustment rate (PCA), overall outcomes for mental health had declined further since our last inspection in 2019 from 68.2% to 41.4%.
  • The practice could not demonstrate how they assured the competence of clinicians working in the practice as there were no systems for supervision or clinical oversight.
  • There were gaps in governance which resulted in oversight in respect of certain aspects of medicines management which had not been identified prior to our inspection.
  • The practice was not always able to demonstrate that systems in place to consider or mitigate risks were effective, or that there was an overall system of oversight to ensure systems were updated or working as intended.
  • There were systems for managing risks, issues and performance, however this needed strengthening to ensure that the services were safe or that the quality was effectively managed.
  • There was limited evidence to demonstrate that the practice involved patients, staff or stakeholders in shaping the service.

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

  • We identified issues with recruitment processes and ongoing employment checks.
  • We found concerns in relation to some of the monitoring of high-risk medicines.
  • There was a lack of systems and processes for oversight of clinicians working in the practice.
  • The practice was not always responsive to the needs of their patients and complaints were not always used to improve the quality of care.

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

  • The practice had taken action which demonstrated that improvements had been made in relation to patient satisfaction for caring.

We found the following breaches of regulations. The provider must:

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

Whilst we found breaches of regulations, we found the provider should:

  • Improve practice processes for recruitment checks.
  • Continue to encourage patients to attend the practice for cervical cancer screening and immunisation appointments.
  • Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
  • Continue to identify patients who may be carers to ensure they receive appropriate support.
  • Embed a system to review patients with do not attempt cardiopulmonary resuscitation (DNACPR) in place.

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 any population group, 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

17 December 2019

During a routine inspection

We carried out an inspection of this service on 17 December 2019 following our annual regulatory review of the information available to us including information provided by the practice.

Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

Are services at this location safe?

Are services at this location effective?

Are services at this location caring?

Are services at this location responsive?

Are services at this location well-led?

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 and requires improvement for the population groups of working age people (including those recently retired and students) and people experiencing poor mental health (including dementia).

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

  • Non clinical staff in patient facing roles had not been appropriately risk assessed or had a review of their immunisation needs against possible infections.

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

  • Measures taken to improve the practice’s uptake of the national screening programme for cervical cancer to date had not been effective. As a result, the practice’s rate for uptake was significantly below the national target.
  • Despite steps taken to increase the outcomes for mental health indicators, the practice were still below national averages and this could be further improved.

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

  • Patient satisfaction rates were significantly lower than local and national averages for data indicators relating to the caring key question. Actions taken in response to this by the practice had not had an impact on levels of patient satisfaction in these areas.

We also rated the practice as good for providing responsive and well-led services because:

  • There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment that met their needs.
  • Patients needs were assessed and care and treatment was delivered in line with current legislation.
  • Risks to patients were assessed and well managed.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider should make improvements:

  • Develop an effective system to risk assess, record and monitor the immunisation status of staff members in line with best practice.
  • Continue work to increase the uptake for cervical, breast and bowel screening.
  • Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
  • Continue work to improve performance and outcomes relating to diabetes.
  • Review procedures in place to demonstrate improved outcomes for patients where satisfaction levels are still low.
  • Continue to work on the uptake of online access for patients.
  • Continue work to identify and support carers registered in the practice.
  • Complete sepsis training for all staff in the practice.
  • Continue with steps to engage with a patient participation group.

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

2 February 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Touseef Safdars practice, Central Clinic, on 14 January 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment

Regulation 11 HSCA (RA) Regulations 2014 Need for consent

Regulation 17 HSCA (RA) Regulations 2014 Good governance

We undertook a focused inspection on 2 February 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Touseef Safdar on our website at www.cqc.org.uk.

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

  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse. Staff were aware of the process and their responsibilities to raise and report concerns, incidents and near misses. We saw that significant events were regularly discussed with staff during practice meetings.
  • Staff assessed needs and delivered care in line with current evidence based guidance. A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. Results were circulated and discussed in the practice.
  • The practice worked with other service providers to meet patient’s needs and manage those of patients with complex needs.
  • The practice had arrangements in place to respond to emergencies and major incidents.
  • Staff files demonstrated that appropriate recruitment checks had been undertaken prior to employment.
  • There were some arrangements for identifying and recording and managing risks, issues and implementing mitigating actions. The risk assessments for fire and legionella contained actions for completion however there were no timeframes or action owners listed on the action plans.
  • The management team encouraged a culture of openness and honesty and staff at all levels were actively encouraged to raise concerns. The practice also sought feedback from staff through an annual staff survey, staff said they felt supported and part of a close team.

The areas where the provider should make improvement are:

  • Keep records to support that risks associated with premises and infection control are adequately managed and to reflect the cleaning of the environment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected Dr Touseef Safdar, Central Clinic, Hall Street, Dudley, on 14 January 2015 as part of a comprehensive inspection. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well-led services. The areas for improvements that led to these ratings also applied to all of the six population groups that we inspected and which are also rated as requires improvement. These were, people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health. We rated the practice good for providing an effective, caring and responsive service.

Our key findings were as follows:

  • The systems in place to ensure patients received a safe service were not robust.
  • The practice did not have effective systems to engage and work in collaboration with other services and health care professionals in the management of patients with complex and long term conditions. The system in place for reviewing patients test results and referrals was not clear. The lead GP did not assess mental capacity in accordance with the requirements of the Mental Capacity Act (2005).
  • Patients were complimentary about the staff at the practice and said they were caring, listened and gave them sufficient time to discuss their concerns.
  • The practice was responsive to the needs of the practice population. There were services aimed at specific patient groups.
  • The leadership structure in place was not clearly defined. Staff spoken with were committed to providing a high quality service. However, they described the overall leadership culture as lacking support and direction.

There were particular areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Operate effective recruitment procedures and ensure that the information required under current legislation is available in respect of all staff employed to work at the practice.
  • Improve engagement and collaboration with other services and health care professionals in the management of patients with complex and long term conditions.
  • Assess mental capacity in accordance with the requirements of the Mental Capacity Act (2005).
  • Have a clear procedure in place for reviewing patients test results and referrals to ensure they are reviewed in a timely manner.
  • Improve the governance arrangements at the practice by assessing, monitoring and mitigating the risks relating to the health, safety and welfare of service users and others. Ensure sensitive patient information is maintained securely and available only to relevant professionals. Seek and act on feedback from staff, for the purposes of continually evaluating and improving the service.

In addition the provider should:

  • Ensure there are systems in place to ensure important information is shared with all staff such as patient safety alerts and the business continuity plan.
  • Have clear processes in place for staff to follow so that patients with no fixed address or those requiring temporary registration can be seen or be registered at the practice.
  • Proactively identify and support those with caring responsibilities.
  • Ensure processes are in place to assure themselves that regular cleaning of the general environment and equipment used for patients care and treatment has been undertaken to an appropriate standard.
  • Ensure records are in place to evidence that clinical staff have relevant vaccinations appropriate to their role in line with the General Medical Council’s Good Medical Practice (GMP) guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 September 2014

During an inspection looking at part of the service

At our last inspection in February 2014, we found that patients were not adequately protected from the risk of abuse because the provider had taken some reasonable steps to identify the possibility of abuse and prevent abuse from happening. We also found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service. We set compliance actions and told the provider to improve.

The purpose of this inspection was to see if improvements had been made since our last inspection in February 2014. We gave the provider short notice of our inspection so that any disruption to patient's care and treatment were minimised. During the inspection we spoke with four members of staff, this included the practice manager, the lead GP (who was also the provider), the practice nurse and a receptionist.

We saw that the provider had made some changes to improve the service and to improve the quality of the care. However, more assessments were required so that the provider could be assured that this was being delivered.

10 February 2014

During a routine inspection

On the day of our inspection we spoke with six patients and five members of staff. One patient said, “The nurse is nice and the reception staff are always polite." Most of the patients we spoke with said they were unable to obtain appointments at a time to suit their needs. However, all the patients we spoke with said they felt the quality of care they received was good.

We saw that patients were treated with dignity and respect. One patient told us, “The staff are well versed in discretion." We saw that patients experienced care and treatment that met their needs.

Patients told us and we saw that care was delivered in a clean environment. Staff required training in safeguarding of vulnerable adults but were aware of whom to report concerns to.

Improvements were required to the quality monitoring systems to assess and monitor the quality of service that patients received. Improvements in patient engagement and management of risks were required.