The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Abubakr Shaikh

Overall: Good read more about inspection ratings

3 Peel Precinct, Carlton Vale, London, NW6 5RE (020) 7372 2172

Provided and run by:
Dr Abubakr Shaikh

All Inspections

14 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Abubakr Shaikh on 31 March 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. In addition, we issued a warning notice to the provider in respect of safe care and treatment and informed them that they must become complaint with the law by 15 July 2016.

A second announced comprehensive inspection was undertaken on 8 December 2016 following the period of special measures. Overall the practice remained rated as inadequate as they had not met the requirements of the warning notice and, as a result, further enforcement action was taken in respect of safe care and treatment and good governance.

In response to the enforcement action taken, the provider sent us an action plan outlining improvements that had been put in place since our previous inspections. We then carried out an unannounced focused follow-up inspection on 4 July 2017 to check that the necessary improvements had been made, or whether further enforcement action was required. At the inspection we found significant improvements had been made to prevent enforcement action although we still found continuing areas of non-compliance in respect of safe care and treatment and good governance.

The full comprehensive reports on the March and December 2016 inspections and the report of the focused follow-up inspection in July 2017 can be found by selecting the ‘all reports’ link for Dr Abubakr Shaikh on our website at www.cqc.org.uk.

This inspection, carried out on 14 December 2017, was an announced comprehensive inspection to review in detail the actions taken by the practice since our December 2016 and July 2017 inspections to improve the quality of care and to confirm that the practice was now meeting legal requirements.

Overall the practice is now rated as 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? – Requires Improvement

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

Our key findings were as follows:

  • The practice had made further improvements since our inspection in July 2017, specifically in respect of infection prevention and control, health and safety and the management of high risk medicines.

  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.

  • 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.

  • Staff had the skills, knowledge and experience to carry out their roles. However, we found that appropriate training had not been provided to support a member of staff in an extended lead role.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • Results of the national GP patient survey, comments cards we received and patients we spoke with showed patients felt they were treated with compassion, dignity and respect and were involved in decisions about their care and treatment.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • Although there were systems and processes in place to support good governance we found that these had failed to ensure safe and appropriate recruitment checks.

  • The practice could not demonstrate stability of management support to ensure the sustainability of the improvements made so far.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Consider how patients with a hearing impairment would access the service.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

4 July 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Abubakr Shaikh on 31 March 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. We also issued a warning notice to the provider in respect of safe care and treatment and informed them that they must become complaint with the law by 15 July 2016.

A second inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 8 December 2016. Overall the practice remained rated as inadequate as they had not met the requirements of the warning notice, and as a result further enforcement action was taken in respect of safe care and treatment and good governance.

The full comprehensive reports on the March and December 2016 inspections can be found by selecting the ‘all reports’ link for Dr Abubakr Shaikh on our website at www.cqc.org.uk.

In response to the enforcement action taken, the provider sent us an action plan outlining improvements that had been put in place since our previous inspections. We then carried out an unannounced focused follow up inspection on 4 July 2017 to check that the necessary improvements had been made or whether further enforcement action was necessary. At the inspection we found significant improvements had been made to prevent enforcement action although we still found continuing areas of non compliance in respect of safe care and treatment and good governance.

Our key findings were as follows:

  • Health and safety processes had improved since our previous inspections however there were still outstanding actions from a NHS England infection control audit and a legionella risk assessment.
  • The arrangements for managing medicines, including emergency medicines and vaccines, in the practice minimised risks to patient safety.
  • The was not an effective system in place for monitoring patients on high risk medicines.
  • Staff had the skills and knowledge to deliver effective care and recruitment checks were in place.
  • Unpublished data from 2016/17 showed improvements in the practices Quality and Outcomes Framework (QOF) performance however performance for depression was still low
  • Although improvements had been made since our previous inspection we observed that staff resources were marginal and not stableand systems and processes were not fully embedded. We were not assured about the sustainability of the improvements made.

The areas where the provider must make improvements are:

  • 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.

In addition, the provider should:

  • Continue to monitor QOF performance and improve patient outcomes.
  • Identify and support more patients who are carers.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

8 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Abubakr Shaikh on 31 March 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Dr Abubakr Shaikh on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 8 December 2016. Overall the practice is now rated as inadequate.

Our key findings were as follows:

  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. There were continuing deficiencies in the systems for infection control, medicines management, emergency equipment and the assessment and management of risk to ensure the safety of patients, premises and equipment.
  • Data showed improvement in QOF performance in a several areas since our previous inspection. However, a number of patient outcomes remained low compared to the national average.
  • There had been improvements in staff training since our previous inspection although documentation of the induction process remained incomplete.
  • Completed full cycle clinical audits were used to drive quality improvements to patient outcomes.
  • Patients were positive about their interactions with staff and said they were treated with compassion, dignity and respect. However, the practice did not have an effective system for proactively identifying patients who were carers to offer them additional support.
  • Patients said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had a number of policies and procedures to govern activity, but some were in need of further review to ensure they were tailored specifically to the practice in all aspects.
  • The practice had an informal governance structure led by the GP. Staff we spoke with were aware of their own roles and responsibilities and felt supported by management.
  • The provider was aware of the requirements of the duty of candour and encouraged a culture of openness and honesty.

Importantly the provider must:

Ensure that premises and equipment are safe and all risks are assessed and mitigated. This includes:

  • Undertaking the full assessment, implementation and monitoring of action arising from risk assessments for infection control, Legionella and Asbestos.
  • Ensuring the proper and safe management of medicines and the security of blank prescriptions forms is in line with guidance.
  • Ensuring emergency and ancillary equipment is safe for use and in line with guidance.
  • Ensuring that staff are suitable to provide services safely, in particular by arranging through the practice for new Disclosure and Barring Service (DBS) checks to be completed for staff whose checks had been made by their previous employer. Where DBS checks have not been carried out for administrative staff, this should be risk assessed and documented to evidence why.
  • Ensuring there is an effective system to assess, monitor and improve the quality and safety of the services provided.
  • Ensuring effective monitoring and recording of the prescribing of high risk medicines.
  • Ensuring policies and procedures to govern activity are practice-specific and up to date.
  • Establishing an effective follow up system to improve quality outcomes for patients with long term conditions and those experiencing poor mental health.

In addition the provider should:

  • Complete documentation to evidence the completion of the induction programme for newly recruited staff.
  • Ensure completed consent forms are included in patient records for all patients who undergo minor surgery.
  • Review systems to improve the identification of carers and provide support.
  • Promote the availability of translation services for patients in the reception area.
  • Arrange for the practice mission statement to be put on display at the practice for patients and staff.

This service was placed in special measures in June 2016. Insufficient improvements have been made such that there remains a rating of inadequate for providing safe and effective services, and there is also now a rating of inadequate for providing well-led services. CQC is taking further action against the provider, Dr Abubakr Shaikh, in line with its enforcement policy, subject to a right of appeal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Abubakr Shaikh on 31 March 2016. This was to follow up a comprehensive inspection we carried out on 5 November 2014 where we found the practice was not meeting the essential standards of quality and safety in a number of areas and overall was rated as requires improvement. The practice had made improvements in some areas but had not addressed sufficiently concerns identified at our previous inspection and we identified additional concerns at our latest inspection. Overall the practice is rated as inadequate.

Specifically, we found the practice to be inadequate for providing safe and effective services, requires improvement for providing well-led services and good for providing caring and responsive services.

The concerns which led to a rating of inadequate in safe and effective services, apply to all population groups using the practice. Therefore, all population groups have been rated as inadequate.

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

  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. There were continuing deficiencies in the systems for infection control, medicines management, emergency and electrical equipment and the assessment and management of risk to ensure the safety of premises and equipment.
  • There were continuing shortcomings in the practice’s recruitment processes, especially evidence of pre-employment reference checks.
  • Data showed some patient outcomes were low compared to the national average.
  • There were continuing gaps in staff training, particularly in relation to ongoing clinical update training for nurses in key areas.
  • Although several clinical audits had been carried out, none were completed full cycle audits used to drive quality improvements to patient outcomes.
  • There was an effective system in place for reporting and recording significant events Patients were positive about their interactions with staff and said they were treated with compassion, dignity and respect.
  • Patients said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had a number of policies and procedures to govern activity, but some were in need of further review to ensure they were tailored specifically to the practice in all aspects.
  • The practice had an informal governance structure led by the GP. Staff we spoke with were aware of their own roles and responsibilities and felt supported by management.
  • The provider was not fully aware of the requirements of the duty of candour. However, the GP encouraged a culture of openness and honesty.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way, through improvements in the safety of infection control processes, medicines management and storage, emergency and electrical equipment and the assessment and management of risk to ensure the safety of premises and equipment.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure gaps in staff training are addressed, particularly in relation to ongoing clinical update training for nurses in key areas and the completion of and recording of the induction process for new staff.
  • Ensure there are appropriate arrangements in place to assess and monitor risk and improve the quality and safety of the services provided including:
  • taking and recording action in all cases following referrals and diagnostic tests;
  • securing improved outcomes for patients with long term conditions and those experiencing poor mental health; and
  • implementing a programme of quality improvement including the completion of audits and re-audits to ensure improvements have been achieved.

In addition the provider should:

  • Arrange for all staff to complete training in safeguarding of vulnerable adults. Update the practice’s policy on safeguarding of vulnerable adults to include details of local agencies to contact for further guidance if staff have concerns about a patient’s welfare.
  • Place a notice in the reception area informing patients a translation service was available.
  • Review practice policies and procedures further to ensure that where model policies have been obtained from external sources these are tailored specifically to the practice in all aspects.
  • Communicate the practice vision and mission statement to all staff and arrange for these to be on display at the practice for patients and staff.
  • Ensure full awareness within the practice of the requirements of the duty of candour.

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.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Abubakr Shaikh on 5 November 2014. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective and well-led services. It also required improvement for providing services for all six population groups: older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances may make them vulnerable; and people experiencing poor mental health (including people with dementia). The practice was good for providing a caring and responsive service.

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

  • The practice worked in collaboration with other health and social care professionals to support patients’ needs.
  • Risks to patients were assessed but systems and processes to address these risks were not implemented well enough in relation to infection control, recruitment, safety and suitability of premises and dealing with foreseeable emergencies.
  • Arrangements were in place to ensure staff were competent to deliver effective care and treatment but there were some gaps in the training undertaken and not all staff had received a recent appraisal.
  • The practice promoted good health and prevention and provided patients with suitable advice and guidance.
  • The practice provided a caring service. Patients indicated that staff were caring and treated them with dignity and respect. Patients were involved in decisions about their care.
  • The practice understood the needs of its patients and was responsive to these. It recognised the needs of different groups in the planning of its services.
  • The practice learned from patient experiences, concerns and complaints to improve the quality of care.

The areas where the provider must make improvements are:

  • Take action to address identified shortcomings with infection prevention and control practice.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Arrange regular health and safety and fire risk assessments, fire alarm testing and fire evacuation drills to ensure the safety and suitability of the premises.
  • Take action to address identified shortcomings in the provision for medical emergencies and arrange relevant training for all staff in accordance with UK Resuscitation Council guidelines.
  • Ensure identified gaps in staff training are addressed and annual appraisals are conducted for all staff.

In addition the provider should:

  • Place significant events and complaints as a standing item on the agenda for practice meetings to demonstrate that the lessons learned from incidents and complaints have been communicated throughout the practice.
  • Arrange for all staff to complete formal training in safeguarding of vulnerable adults.
  • Complete a documented risk assessment stating the rationale for not carrying out a criminal records check for some non-clinical staff.
  • Take steps to communicate the practice’s chaperone policy more clearly to patients.
  • Ensure non-clinical staff who occasionally act as chaperones undergo a criminal records check.
  • Formally record the checks of medicine expiry dates and medical emergencies equipment.
  • Install an emergency pull cord in the patients’ toilet.
  • In addition to annual calibration checks carried out currently, arrange regular testing of portable appliances to ensure equipment is safe and suitable.
  • Review practice policies and procedures in a systematic way to ensure they remain up to date and relevant and where model policies had been obtained from external sources these are tailored specifically to the practice in all aspects.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice