Dr Imran Gohar Also known as SYDENHAM HOUSE DOCTORS SURGERY

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. Staff did not always have the required mandatory training, and there were gaps in required recruitment checks. Evidence was received after the inspection confirming that relevant action had been taken.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified risks. We identified outstanding actions in the fire and legionella risk assessment and the provider sent us an action plan which detailed how these were going to be addressed. There were regular fire drills as well as systems to ensure that patient safety alerts relating to premises were cascaded. Emergency equipment was checked regularly, and calibration testing ensured equipment was fit for use.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The service did not always ensure that staff were recruited safely or had received required training. During our inspection we looked at 4 staff files. We identified gaps in training records, including Mental Capacity Act, Infection Prevention and Control, Learning Disability and Autistic People Support and Recognising the Deteriorating Patient. One member of staff was recruited and worked across the practice and another neighbouring practice. They did not have any training records, although the provider assured us that these were in place. Following the inspection, we were sent a copy of the training matrix which confirmed that most mandatory training had been completed, either before or since the inspection.

There was no checklist completed during recruitment to identify which checks were outstanding. We found omissions relating to address identification, references and a check of the Performers List for a GP. The practice manager had requested Disclosure and Barring Service checks but had not undertaken a risk assessment to identify and mitigate concerns whilst waiting for these to be issued. We were sent evidence to confirm that these issues were immediately rectified following the inspection.

Staff did receive support, supervision and development, although this was not always documented. As a small practice, the clinical and non-clinical team met daily. Staff told that they did receive regular appraisals and supervision. After the inspection, we were sent an appraisals and supervisions plan which detailed how and when appraisals were to be recorded.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service had been recently renovated, and flooring was appropriate coved in treatment areas, and sinks were compliant. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. Records sent to us after the onsite inspection confirmed that staff had completed relevant training in infection prevention and control.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.