You are here

Dr Mahreen Chawdhery Good Also known as 306 Medical Centre

Inspection Summary


Overall summary & rating

Good

Updated 15 August 2016

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection of Dr Mahreen Chawdhery on 26 May 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Ensure that systems are in place for ongoing risk assessment of the medicines required to respond effectively in an emergency.

  • Should ensure that all staff are aware of practice safeguarding leads and the correct procedures for chaperoning.

  • Ensure that the practice’s business continuity plan contains emergency contact information for all staff working at the practice.

  • Undertake a programme of quality improvement to improve patient outcomes.

  • Review the training and support arrangements for the practice nurse to ensure that they receive adequate peer support from nurses within the locality.

  • Review ways to improve patient confidentiality for consultations that are carried out in the nurses room.

  • Ensure complaints responses follow practice policy and comply with requirements of The Local Authority Social Services and NHS Complaints (England) Regulations 2009.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 August 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse; although some staff we spoke with were not aware of the safeguarding lead within the practice and did not know the correct procedure for chaperoning.

  • Risks to patients were assessed and well managed.

Effective

Good

Updated 15 August 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • We saw example of clinical audits, although none of those initiated by the practice demonstrated quality improvement.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

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

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 15 August 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice in line with national averages for several aspects of care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality. However some conversations in the nurse’s room could be heard from the reception area.

Responsive

Good

Updated 15 August 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. However responses did not always provide patients with details of external organisations who they could escalate concerns to if they were dissatisfied with the practice’s response. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 15 August 2016

The practice is rated as good for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.

  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. Although this included arrangements to identify risk, there was little evidence of effective systems to improve quality.

  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.

  • The practice proactively sought feedback from staff and patients, which it acted on. The Patient Participation Group was active.

Checks on specific services

People with long term conditions

Good

Updated 15 August 2016

The practice is rated as good for the care of people with long-term conditions.

  • Staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

  • The practice scored higher than the national average on diabetic indicators.

  • Longer appointments and home visits were available when needed.

  • People with long term conditions were offered flu vaccinations.

  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

  • The practice provided evidence that they were set a target by the federation to complete 145 care plans for patients with long term conditions during 2016/17 but as at 8 April 2016 had completed 417 care plans.

Families, children and young people

Good

Updated 15 August 2016

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of Accident and Emergency (A&E) attendances.

  • Immunisation rates were relatively high for all standard childhood immunisations.

  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

  • The percentage of women aged 25-64 whose notes record that a cervical screening test has been performed in the preceding 5 years was comparable to national averages.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • We saw positive examples of joint working with midwives (which the practice hosted) and health visitors.

  • The practice offered a “one stop child health clinic” for health visitor checks and immunisations.

  • The GP principal provided a family planning clinic which could also be utilised by patients at a neighbouring practice.

Older people

Good

Updated 15 August 2016

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

  • Four per cent of the practice’s population were over 75. All patients in this demographic were reviewed annually and were assessed holistically where appropriate. The practice participated in the Holistic Health Assessment Scheme; which aimed to assess and provided packages of care designed to meet the health and social needs of those over 65 who are housebound or have not attended the GP in 15 months or those over 80. Although this initiative was traditionally nurse led within the locality we were informed that the GP principal had attended training on this. We saw evidence of Holistic Health Assessments undertaken by the principal GP and a letter of thanks provided by the relative of one patient for the difference that the GPs intervention had made.

Working age people (including those recently retired and students)

Good

Updated 15 August 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)

Good

Updated 15 August 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • 100% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is above the national average.

  • Other mental health indicators were in line with the national averages.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

  • The practice carried out advance care planning for patients with dementia.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • Staff had a good understanding of how to support patients with mental health needs and dementia.

  • The practice hosted a psychotherapist provided by a NHS mental health organisation.

People whose circumstances may make them vulnerable

Good

Updated 15 August 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

  • The practice had signs in all clinical rooms which provided guidance to clinicians on how to assist those with communication issues to ensure that those with disabilities or who did not speak English as a first language were supported and fully informed about decisions regarding their care and treatment.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns. However some staff were not aware of the practice’s safeguarding lead.