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Inspection Summary


Overall summary & rating

Good

Updated 1 August 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Azim and Partners on 31 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr Azim and Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice appraised all members of staff on an annual basis. New members of staff have three formal reviews within the first six months of employment as well as an annual appraisal.

  • All staff had access to training via an online training programme. All staff had completed mandatory training such as basic life support training and fire safety training.

  • The practice updated their recruitment policy and all new members of staff had appropriate pre-employment checks in place.

  • The practice enhanced their induction programme and all new members of staff had a comprehensive six month induction with support in place.

  • The practice had a system in place to ensure patient safety alerts were monitored and acted upon.

  • The practice took actions to increase the uptake in cervical screening. For example the practice increased the number of clinicians trained to provide cervical screening from one nurse to three nurses and two GPs. The practice targeted patients whose first language is not English and provided an educational workshop on the importance of participating in cervical screening.

  • The practice displayed a health and safety poster in the reception area with appropriate contact information.

  • The practice identified 97 carers, more than 1% of the patient population.

  • The practice developed a three year business plan to enable management to monitor future development of services within the practice.

  • The practice developed a business continuity plan which included a neighbouring practice which can provide temporary space for clinical consultations and emergency contact numbers. All staff had access to the plan.

  • The practice developed a mission statement; all staff were included in creating the mission statement. The practice posted the core values in the administration area as a reminder to all staff, the mission statement was on display in the patient waiting area.

At our previous inspection on31 August 2016, we rated the practice as requires improvement for providing safe and effective services as there was gaps in the recruitment and induction process for new staff, the system for managing patient safety alerts did not have a fail-safe mechanism and not all staff were supported with training relevant to their role and annual appraisals. At this inspection we found that the practice had taken action to improve all the areas we identified as required improvement at the inspection in August 2016. Consequently, the practice is now rated as good for providing safe and effective services which means the overall rating of the practice is good.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 1 August 2017

The practice is rated as good for providing safe services.

  • The practice had carried out complete pre-employment checks on all staff employed.

  • There was evidence that staff had received training in safeguarding of children and vulnerable adults.

Effective

Good

Updated 1 August 2017

The practice is rated as good for providing effective services.

  • There was evidence of appraisals and personal development plans for all staff.

  • Staff had completed all mandatory training including: basic life support training; and fire safety training.

  • There was evidence of a fail-safe system to ensure that clinical staff reviewed and acted upon medicines alerts.

  • There was evidence of a comprehensive induction programme for new members of staff.

Caring

Good

Updated 1 August 2017

Responsive

Good

Updated 1 August 2017

Well-led

Good

Updated 1 August 2017

Checks on specific services

People with long term conditions

Good

Updated 1 August 2017

The provider had resolved the concerns for safe and effective identified at our inspection on 31 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 1 August 2017

The provider had resolved the concerns for safe and effective identified at our inspection on 31 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 1 August 2017

The provider had resolved the concerns for safe and effective identified at our inspection on 31 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 1 August 2017

The provider had resolved the concerns for safe and effective identified at our inspection on 31 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 1 August 2017

The provider had resolved the concerns for safe and effective identified at our inspection on 31 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 1 August 2017

The provider had resolved the concerns for safe and effective identified at our inspection on 31 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.