Archived: Dr Mohamedtaki Walji

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

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.
We assessed all the quality statements in this key question and found that systems were in place to enable safety to be monitored, managed and maintained. Safeguarding processes worked well to make sure people were protected. Infection prevention and control was well-managed. The provider investigated, learned and shared the learning from significant events but it was not evident that all such events were being captured by their reporting system. We found some shortfalls in the equipment and processes to manage medical emergencies. The provider had not identified and mitigated all potential risks in the care environment. The provider did not clearly identify the mandatory training staff had to complete or have an effective system in place to monitor compliance. Prescribing of a specific medicine to one group of vulnerable older people was not in accordance with national guidelines and exposed those people to risk. The security of prescription stationary was not robust or well-managed.
The provider was in breach of legal regulation in relation to safe care and treatment.
 

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did have a culture of investigating and learning from events. Significant events and complaints were investigated thoroughly. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture and when things went wrong, staff apologised when appropriate and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.
However, the number of both complaints and clinically significant events recorded by the provider’s system was very low for the size of the practice. Although reporting processes were in place and staff understood them, there was evidence of under‑reporting; for example, only two significant events had been recorded in the past 12 months. This limited the organisation’s ability to learn and improve, and leaders had not considered or reviewed the possibility of under‑reporting. Although there was an annual review of complaints and significant events by the leadership team, we found that the provider had a paper-based system and this did not help maintain an overview of any themes or trends. The lack of an effective system made it harder to have regular, clear oversight of both the number and nature of learning events between annual reviews. When we raised this with the provider, they reminded staff about the importance of following the process for reporting incidents. They also implemented a spreadsheet to record complaints and significant events.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different providers. There were systems in place for processing information relating to new patients. The provider worked with other providers to deliver shared care and when patients moved between providers. Correspondence, referrals, test results and prescription requests were managed in a timely way, with a specific GP having responsibility for each area. Safety-netting arrangements were in place to ensure that patients referred on a two week wait pathway received an appointment within the agreed timeframe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Safeguarding concerns were a standing agenda item at weekly staff meetings so that all clinical staff maintained oversight of vulnerable patients.
Safeguarding policies were in place and known to staff however, not all administrative staff had received the appropriate level of training. When we raised this with the provider, they took immediate action to ensure that all administrative and reception staff completed the correct level of training. The practice training matrix was amended to ensure that all staff understood which level they were required to complete for their job role.
 

Emergency equipment was available and accessible to all staff. Staff could recognise a deteriorating patient and knew of action to take. All staff were trained to an appropriate level in life support. There were appropriate systems in place to manage medical emergencies including summoning help. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

However, some important equipment was not stored within the emergency grab bag. For example, scissors and a shaving razor are required to enable staff to remove clothing quickly and safely perform defibrillation in the event of a cardiorespiratory arrest. Neither of these items was available in the grab bag. Some small items of equipment such as a thermometer, a blood pressure monitor and a pulse oximeter (a machine that measures the oxygen level in the blood) were available in clinical rooms but not stored together in the emergency grab bag. All emergency medicines were available but they were stored in two areas, some in the grab bag and some in the drug cupboard in reception. These storage issues could potentially cause delay in accessing emergency medicines and equipment. Staff made weekly checks of the defibrillator, but all other checks of emergency equipment and medicines were carried out monthly. Guidance from the Resuscitation Council UK states that these checks should be carried out at least weekly. Providers should have a risk assessment that includes a rationale for a not stocking a recommended item of equipment or medicine based on the patient groups seen by the service, the likelihood of cardiorespiratory arrest and the availability of other services. This risk assessment was not in place for a medicine used to treat opioid overdoses. When we raised these concerns with the provider the took immediate action to rectify the situation.

The provider premises had one large waiting area in front of the reception desk and a smaller waiting area at the back of reception, which faced several clinical rooms. At certain times of the day this small waiting could not be easily observed by reception staff, meaning that should a patient be waiting there alone and have a medical emergency they were not visible to staff. There was an informal agreement in place amongst the reception staff that at quiet times they asked all patients to wait in the front area and clinical staff would be informed to call them from there. However, there was no formal risk assessment or policy in place. Following our inspection the provider implemented a standard operating procedure (SOP).
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.
The practice is located in a purpose-built health centre shared with other services and managed by NHS Property Services (NHSPS). The premises were clean, spacious and appropriate for use. There were up-to-date records to show that water safety checks, portable electrical appliance testing and calibration, electrical and gas safety were monitored and managed appropriately.
However, at the time of our inspection the provider was not aware that the fire risk assessment commissioned by NHSPS only covered the communal areas of the building and not those rooms and offices used by the provider. Therefore, no fire risk assessment was in place for these areas. When we raised this with the provider, they undertook a basic fire risk assessment, but this was not adequate as it did not address all the risks for example, it did not cover the safe storage and use of oxygen which is a fire hazard. However, all fire detection and fire fighting equipment was in place and had been regularly tested and serviced. The practice had trained fire marshals on duty each day and a successful fire drill had been completed in the last 12 months.
At the time of our inspection the provider did not have a comprehensive health and safety risk assessment in place and not all staff had completed health and safety training. Some individual health and safety risk assessments had been undertaken in response to specific incidents such as a leak. Following our inspection the provider completed an in-house health and safety risk assessment, but it was not adequate as it did not identify all the potential risks, it did not include any risk grading and did not specify the mitigations put in place to manage the risks.
The provider did not have a policy or risk assessment for the care of substances hazardous to health (COSHH). Leaders told us that as cleaning services were provided by an external company contracted by NHSPS they may have a COSHH risk assessment, but they were not certain. Following our inspection the provider produced a COSHH risk assessment, but it was not adequate as it did not identify all the potentially harmful substances used within the practice, it did not include any risk grading and did not specify the mitigations put in place to manage the risks.
 

There were enough qualified, skilled and experienced staff however, not all staff had completed the relevant mandatory training for their role.
There were a range of clinical and non-clinical roles within the practice. Staff files we reviewed showed that staff were suitably qualified for their role and had completed role-specific training. For example, practice nurses had completed recent immunisation updates. Of the files we reviewed all staff had 360-degree appraisals in the last 12 months. 360-degree appraisal systems incorporate feedback about the individual from colleagues at all levels in the organisation.
However, although staff and leaders reported that appropriate arrangements were in place to provide staff with clinical supervision there was no formal record of supervision discussions. This meant the practice was unable to evidence that supervision was taking place regularly and had no record of feedback given to staff during supervision.
During our inspection we found that the provider did not have a clear list of the required mandatory training for each job role, including the level of training required and the frequency with which it must be repeated. Paper records included an incomplete list of training that the practice required staff to complete for example, it did not include fire safety or health and safety training. The system of paper records was disorganised and made it difficult to ascertain which staff completed which training. Of the four staff training records we reviewed during this inspection only one staff member had completed equality and diversity training, one had completed manual handling training, one had completed health and safety training and no one had completed fire safety training. However, following further review some staff were able to produce certificates to evidence that the training had, in fact been done however, it had not been recorded. This meant that the leadership team did not have clear oversight of compliance with training.
Administrative and reception staff had not completed the correct level of safeguarding training for children or adults for their patient-facing role. When we raised this with the provider, they provided evidence during the inspection to show that all affected staff had since completed the training.
We found that the recruitment process for a new GP partner had not followed the provider’s own policy as references had not been requested or obtained because the person was known to members of the leadership team. Following our inspection the provider requested and provided the relevant satisfactory references.
We received information raising concerns about recruitment practices, specifically regarding changes to certain roles shortly after employment began. The provider told us that applicants had been appointed to initial roles with the possibility of progression discussed at interview. They reported that this had been agreed in advance and that staff were completing the relevant training for the transition.

The provider did not always assess or manage the risk of infection.
The practice had a designated infection, prevention and control (IPC) lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Most risk assessments and audits were completed, and actions taken to mitigate risks.
The provider’s IPC policy was generic and did not contain all the required information specific to the practice. For example, it did not state how often IPC audits would be carried out, who was responsible for completing actions arising from audits or what the process of managerial oversight was. Following the inspection the provider updated and expanded their IPC policy to include this information.
The policy regarding the handling of specimens of bodily fluids was not adequate. Non-clinical staff are frequently required to accept specimens from patients which risks their exposure to bodily fluids such as blood or urine. Policies should be in place that assess the likelihood and severity of this risk and set out the mitigations in place to reduce it. For example, staff should don gloves before accepting samples and wash their hands afterwards. This is especially important if staff have any uncovered open cuts or abrasions on their hands or if they have chosen not to be vaccinated against certain diseases such as Hepatitis B. The provider’s policy did not address these issues or minimise the risk to staff. Following this inspection the provider included within the policy instructions regarding the use of personal protective equipment for staff handling specimens.
During our inspection we found one clinician’s chair in a clinical room that was fabric covered and did not meet IPC standards as it was not wipeable. There was no specific plan in place to clean this chair adequately to minimise the infection risk. When we raised this with the provider, they advised that they would purchase a new chair.
 

The provider did not always make sure that medicines were managed safely.
Staff involved people in reviews of their medicines and people knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff felt confident managing the storage, administration and recording of medicines. Mostly staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. The provider had effective systems to manage and respond to safety alerts and medicine recalls. A range of audits had been completed to improve the prescribing of specific medicines such as medicines for the treatment of incontinence and osteoporosis which had resulted in tangible improvements for patients.
However, during our clinical searches we found that a significant proportion of patients who were over the age of 65 and taking either an anti-inflammatory painkiller or a medicine to prevent blood clots had not been prescribed an additional medicine to prevent damage to the lining of the stomach and gut. Both of these groups of medicine can cause ulcers and internal bleeding, taking the additional medicine reduces the risk of this happening. In a more vulnerable elderly population, the risk of internal bleeding and poor subsequent outcomes is increased. All of these patients had undergone a medication review with either a GP or Pharmacist in the previous 12 months and yet this omission had not been identified, showing that these medication reviews had not been effective. Following the inspection the provider identified all affected patients, reviewed their medicines and amended their treatment as necessary. They also put in place systems to prevent future recurrence including regular clinical searches for this cohort of patients which were reviewed by a clinical pharmacist and a warning pop-up on the clinical system whenever these medicines were prescribed.
Although a system was in place to audit the prescribing practice of non-medical prescribers such as the advanced nurse practitioner this did not extend to the medical prescribers. Prescribing audits are important to identify areas of poor practice for example over-prescribing of antibiotic medicines as well as ensuring that prescribing is in line with local formularies and national guidelines. Without this type of audit leaders do not have clear oversight of prescribing practice in order to identify trends or outliers that require action. Following the inspection the provider told us they would consider implementing prescribing audits for all prescribers.
The practice did not have robust security arrangements for the safe management of prescription stationary. After deliveries were logged, prescription stationary was stored in a locked cupboard in the reception area. All clinical staff could access the key for this cupboard and prescribers took prescription stationary without logging the serial numbers to a specific person or clinical room. During our inspection we found excessive amounts of prescription stationary in unlocked printers. This stationary was not removed at the end of the working day. Leaders told us that very few paper prescriptions were issued, as most prescriptions were sent electronically, so there was no reason for large amounts of scripts to be left in printers. When we asked the provider about this, they reviewed their processes and updated their policy. However, the new process relied on staff to complete a paper form with the serial number of the first and last script they took but allowed staff to take 20 scripts at a time. Given the infrequent of use of paper prescriptions staff should only take the minimum number of scripts at a time to reduce the risk of loss, theft or fraud.