Dr Dauod Yosuf Abdulrahman Shantir Also known as Dauod Yosuf Abdulrahman Shantir

We carried out an announced comprehensive inspection at Dr Dauod Yosuf Abdulrahman Shantir on 2 July 2019 to follow up on breaches of regulation identified in medicines management, safeguarding, infection prevention and control, clinical governance and patient satisfaction, identified in a comprehensive inspection on 10 October 2017, which had not improved on a further comprehensive inspection on 14 November 2018, where the practice was placed in special measures.

This inspection in July 2019 found that all previous breaches identified had been rectified.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall.

We rated the practice as good for providing safe services because:

• There were clear systems and processes to keep patients safe and safeguarded from abuse.
• The practice had appropriate systems in place for the safe management of medicines, including managing the cold chain.
• The practice completed several risk assessments including fire and infection prevention and control. The practice also monitored the risk assessments routinely completed by the premise’s management team on behalf of the practice.
• There was a suite of policies and procedures that were effectively managed and maintained.
• All electrical and clinical equipment had undergone testing to make sure they were safe and fit for purpose.

We rated the practice as good for providing effective services because:

• There was evidence of quality improvement activity.
• The practice was effectively monitoring their exception reporting.
• Childhood immunisation rates were in line with national averages.
• Staff had the skills, knowledge and experience to carry out their roles.

We rated the practice as good for providing caring services because:

• The practice was able to demonstrate action that had been taken to improve patient satisfaction.
• The practice’s own patient satisfaction survey showed patients were happy with the care and treatment they received.
• Completed CQC patient comment cards and patients we spoke with all indicated that the practice had a caring nature and were attentive to the needs of patients.
• The practice had identified 1% of their patient population as a carer and had systems to ensure that they were aware of the services available to them.

We rated the practice as good for providing well-led services because:

• The practice had appropriately addressed the warning notice in relation to governance arrangements and safe care and treatment.
• The practice had recruited a business manager and leaders showed that they had the capacity and skills to deliver high quality sustainable care.
• The practice had a clear vision, which was supported by a credible strategy.
• There were sufficient processes for managing and mitigating risks.
• All staff members had clear roles, responsibilities and accountabilities.

We rated the practice as requires improvement for providing responsive services because:

• Whilst the practice demonstrated that they had made a lot of improvements to access to services it was too early to ascertain the impact that this has made.
• The practice had increased their opening hours and the number of appointments available for patients.
• The practice had installed a new telephone system which it was monitoring and 91% of all calls were answered and 76% of these were within two minutes.
• Patients who contacted the practice more than once on a given day and were unable to get through to the practice received a call back where their needs were attended to.
• The practice carried out their own patient satisfaction survey which showed that patients were happy with access to services.
• Patients we spoke with told us that there had been an improvement in being able to contact the practice by telephone.

Whilst we found no breaches of regulations, the provider should:

• Continue to work to ensure that all the improvements made are sustained.
• Review the prevalence of patients with diabetes in the practice.

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

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We previously carried out an announced comprehensive inspection of Dr Dauod Yosuf Abdulrahman Shantir on 14 November 2018 and found that the practice was in breach of Regulation 17: ‘Good governance’ of the Health and Social Care Act 2008. In line with the Care Quality Commission’s (CQC) enforcement processes, we issued a warning notice which required the practice to comply with the Regulations by 11 March 2019.

The full report of the 14 November 2018 inspection can be found by selecting the ‘all reports’ link for the Dr Dauod Yosuf Abdulrahman Shantir practice on our website at .

We carried out this announced focussed inspection on 9 April 2019 to check whether the practice had addressed the issues in the warning notice and now met the legal requirement. This report covers our findings in relation to those requirements and will not change the current ratings held by the practice.

At this inspection on 9 April 2019 we found the provider had taken action to address the requirements of the Regulation 17 warning notice.

Our key findings were as follows:

• The practice had completed a number of risk assessments including infection prevention and control and a fire risk assessment. All actions in relation to these had been completed.
• There was a system for managing and maintaining the cold chain.
• Inadequate rates for cervical cytology was effectively monitored.
• There was a new suite of policies and procedures including safeguarding and infection prevention and control, these were version controlled and accessible to all staff on the practice computer shared drive.
• The practice had carried out its own patient satisfaction survey, the results of which were higher than the national GP patient survey.
• The practice had reviewed their exception reporting practices.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as inadequate overall. (Previous rating 10 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Inadequate

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Dr Daoud Yosuf Abdulrahman Shantir on 10 October 2017, to follow up on breaches of regulations identified in medicines management, clinical governance and patient satisfaction, identified in a comprehensive inspection in December 2016.

This inspection in November 2018 was an announced comprehensive inspection to confirm that the breaches in clinical governance and documentation and patient satisfaction, identified in the inspection carried out in October 2017 had been rectified.

At this inspection we found:

• Safeguarding systems were not clear and did not keep patients safe and safeguarded from abuse.
• The practice did not have systems to monitor or manage the outcomes and ongoing actions associated with risk assessments such as fire and infection prevention and control.
• Insufficient improvement had been made in relation to patient satisfaction with access to the practice.
• Policies and procedures were not effectively maintained, managed or stored.
• The vaccine refrigerator temperature was not effectively monitored.
• Inadequate smear rates were not monitored or managed.
• There was no evidence that calibration of clinical equipment had taken place.
• The practice did not effectively maintain personnel records for some clinical members of staff, including training records, professional indemnity and professional registration status.
• There was an effective system to monitor uncollected prescriptions.
• The practice monitored patient safety alerts and made effective use of clinical guidelines when making decisions.
• There was an open transparent approach to reporting and recording significant events.
• Information about services and how to complain was readily available. Improvements were made to the quality of care as a result of complaints and concerns.

The areas where the provider must make improvements as they are in breach of regulations 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.

The areas where the provider should make improvements are:

• Continue to review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
• Consider ways to improve confidentiality in the reception area.

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.

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