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Dr Yahaya Mohammed Good Also known as Hollington Surgery

Inspection Summary


Overall summary & rating

Good

Updated 31 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Yahaya Mohammed on 27 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Dr Yahaya Mohammed on our website at www.cqc.org.uk

This inspection was an announced focused inspection carried out on 13 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

During our inspection on 13 June 2017, our key findings were as follows:

  • There was evidence that lessons learned were the subject of whole practice discussion and review in meetings.

  • Risks to patients who used services were identified and assessed, and actions taken to mitigate risks were sufficient.

  • There was a new recruitment policy and induction process for all newly recruited staff.

  • The arrangements for managing medicines, including emergency medicines and vaccines, in the practice kept patients safe. Medicines and blank prescriptions were stored and kept securely and there was a procedure in place to manage refrigerated medicines.

  • All staff had received basic life support training. There was a written record of regular defibrillator and oxygen checks.

  • Mandatory training was up-to-date and planned for all staff.

  • An infection control audit had been conducted and actioned.

  • There was evidence of engagement with patients and their involvement in improving services.

  • Quality and Outcomes Framework data from 2015/16 showed patient outcomes had improved from the previous year.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Continue to improve patient outcomes in relation to national QOF data.
  • Continue to ensure that all staff are up-to-date in mandatory training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 31 July 2017

The practice is rated as good for providing safe services.

  • Minutes of meetings demonstrated opportunity for whole practice discussion and review of lessons learned.

  • Risks had been identified and action taken to mitigate these.

  • The recruitment policy had been reviewed, with the practice making reference to schedule 3 of the Health and Social Care Act as part of procedure. The induction checklist for all newly recruited staff had also been reviewed and included a checklist of required training for staff.

  • Arrangements for managing medicines, including emergency medicines and vaccines, in the practice kept patients safe. Medicines and blank prescriptions were stored securely.

  • The practice had appropriate emergency equipment and medicines. There were regular checks of the defibrillator and medical oxygen. Fridge temperatures were regularly checked and recorded.

  • A carpet in a treatment room identified as a result of an infection control audit had now been removed and replaced.

  • All staff had received annual basic life support training within the last 14 months.

Effective

Good

Updated 31 July 2017

The practice is rated as good for providing effective services.

  • Most staff had completed mandatory training. We saw in one instance where this was not the case, staff had been booked onto the next available course.

  • QOF data (QOF is a system intended to improve the quality of general practice and reward good practice) showed patient outcomes in 2015/16 had improved.

Caring

Good

Updated 30 January 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others 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.

Responsive

Good

Updated 30 January 2017

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. For example, they provided extended hours appointments for patients unable to access the practice during normal working hours.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent and routine 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. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 31 July 2017

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

  • Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were sufficient.

  • There was evidence of seeking feedback from patients following their appointments. The practice used patient feedback to improve services and facilities.

  • Recruitment and induction policies had been reviewed and were compliant with regulations.


Checks on specific services

People with long term conditions

Good

Updated 31 July 2017

The provider had resolved the concerns for the safe, effective, and well-led domains previously identified at our inspection on 27 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 31 July 2017

The provider had resolved the concerns for the safe, effective, and well-led domains previously identified at our inspection on 27 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 31 July 2017

The provider had resolved the concerns for the safe, effective, and well-led domains previously identified at our inspection on 27 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 31 July 2017

The provider had resolved the concerns for the safe, effective, and well-led domains previously identified at our inspection on 27 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 31 July 2017

The provider had resolved the concerns for the safe, effective, and well-led domains previously identified at our inspection on 27 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 31 July 2017

The provider had resolved the concerns for the safe, effective, and well-led domains previously identified at our inspection on 27 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.