Archived: Dr Abdul Naeem Also known as Dog Kennel Lane Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of legal regulation in relation to:

• Governance processes were ineffective in assessing, monitoring and mitigating the risks relating to the health, safety and welfare of people.

We found governance processes needed improvement to ensure there were safe systems in place. The management of medicines required strengthening to provide the appropriate care and treatment to people. Health and safety assessments including infection control were not effective in mitigating risks and we identified gaps in staff training and no effective systems to monitor the skills and knowledge of staff so people had safe care and treatment.

Leaders and staff shared a clear vision and culture in listening and mutual trust. Staff told us the leadership team were supportive. Staff reported feeling empowered to provide feedback and described a workplace culture that promoted equality and was free from bullying or harassment. Roles and responsibilities were well understood across the team. We found limited evidence of a culture of continuous improvement, with learning not being shared with the practice team to improve the quality of services and mitigate any future risks and no effective processes in place to ensure staff were up to date with training relevant to their role.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There were systems to ensure compliance with the requirements of the duty of candour, however we were unable to gain assurances there was an open culture and clear learning within the practice. Regular meetings were held with staff and the management team encouraged the reporting of incidents, but on reviewing minutes of staff meetings we found no evidence to demonstrate learning from incidents was shared with the team to identify ways in which the practice could continually improve. We also identified a range of staff who had not completed training deemed mandatory by the provider.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care.

The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. However, we were unable to gain assurances that learning from incidents was shared with the practice team to identify learning and mitigate future risks. We reviewed a random sample of minutes of meetings and found no incidents had been discussed. The practice had a significant events policy and a reporting form had recently been implemented, which was accessible to all staff members.

The practice had a system in place to record and investigate complaints. The practice had a complaints procedure in place. We reviewed a random sample of complaints and found the provider had responded in a timely manner and had offered apologies to people. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Feedback and information were available in the practice and on their website. The outcome of the GP National Patient survey showed people had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were well supported and felt able to ask for advice.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found governance processes required improvement to ensure risks were mitigated. For example, the monitoring of people on high-risk medicines and people with long term conditions. Safeguarding registers were in place, but further strengthening was required to ensure there were clear oversight of safeguarding concerns. Staff who had been given extra roles told us they worked part time and were unable to complete these roles due to time restraints, for example, infection control. Health and safety risk assessments were in place; however, these had been completed 2 days prior to the onsite assessment and the provider was unable to provide evidence to demonstrate previous assessments had been completed. We also found staff training was not monitored effectively with limited oversight.

Staff could access all required policies and procedures. Managers held regular practice meetings with staff, but on reviewing minutes of meetings we found no evidence to demonstrate identified risks had been discussed to share learning and mitigate future risks. Staff took patient confidentiality and information security seriously.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

Regular meetings were in place; however, we found learning was not shared from incidents and limited evidence improvement plans were regularly discussed.

We were told by the leadership team that they were trying to set up a patient participation group (PPG), however on speaking to previous members of the PPG they were unaware of a new PPG and had not been approached to attend a meeting. Information on the practice website encouraged patients to attend the PPG, however the information about the group was not correct, with the website informing people the group met every 3 months to discuss many aspects of the surgery's performance.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We found regular staff meetings were in place, however we found no evidence to demonstrate that learning from incidents was shared with the practice team to promote learning, mitigate future risks and improve the quality of the services provided.

We identified concerns in the management of staff training with no clear oversight of what training was outstanding. We found gaps in safeguarding updates, mental capacity act and health and safety.

The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.