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Dr Yahaya Mohammed Good Also known as Hollington Surgery

Reports


Inspection carried out on 13 June 2017

During an inspection to make sure that the improvements required had been made

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 carried out on 27 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Yahaya Mohammed on 27 September 2016. Overall the practice is rated as requires improvement.

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

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses and when things went wrong reviews and investigations were undertaken. There was evidence that lessons learned were being communicated, however minutes of meetings did not demonstrate whole practice discussion and review.

  • Although some risks to patients who used services were assessed, there were areas where risks had not been identified. For example, there was a lack of general environmental risk assessments, DBS (disclosure and barring service) risk assessments and legionella risk assessment. In other areas there were risk assessments but action taken to mitigate the risk was insufficient. For example, the lack of fire drills being conducted and appropriately recorded.

  • There were recruitment checks but a nurse recruited from an agency did not have references on record and a healthcare assistant did not have a DBS in place, although one had been applied for.

  • The arrangements for managing medicines, including emergency medicines and vaccines, in the practice did not always keep patients safe. Blank prescriptions were not stored or kept securely and there were refrigerated medicine management issues.

  • There were emergency procedures. However, one of the GPs was not up to date with basic life support training, there was no record of regular defibrillator checks and there was expired aspirin in the box of emergency medicines.

  • Mandatory training was not up to date for all clinical staff.

  • There were infection control processes and an audit had been undertaken with clear evidence of action having been taken by the practice, with the exception of a carpet in a treatment room which was due to be removed but there was no clear timeline for this.

  • There were systems to keep patients safeguarded from abuse and all staff had received training at an appropriate level.
  • There was limited evidence of proactive engagement with patients and their involvement in improving services. Although we were told that a virtual patient participation group (PPG) was in existence and there were plans to develop this further, there was no evidence of the practice being proactive in approaching the PPG.
  • Data showed patient outcomes were low compared to the national average in 2014/15. However, 2015/16 figures showed improvements from the previous year, with evidence of audits being used to drive improvement.

  • Multidisciplinary working was taking place with representation from external professionals including health visitors and palliative care specialists.

  • Patients said they were treated with compassion, dignity and respect, that staff were friendly and approachable and listened to them.

The areas where the provider must make improvements are:

  • Ensure that medicines management processes are implemented to keep patients safe.

  • Ensure that emergency equipment is monitored and recorded appropriately.

  • Ensure that all staff have up to date mandatory training and that induction processes are clearly recorded.

  • Ensure that risks within the practice are appropriately assessed including those relating to the environment and legionella and that appropriate mitigating actions are taken and monitored to manage those risks identified.

  • Ensure recruitment arrangements include all necessary pre-employment checks for all staff.

  • Ensure that infection control audits and action as a result are ongoing and that improvements are monitored.

  • Ensure that the patient participation group is active and that patient feedback is utilised through the use of surveys.

In addition the provider should:

  • Continue to take action to improve patient outcomes in relation to national QOF data.
  • Ensure that there is a clear record of meeting minutes relating to discussions around significant events.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 11 December 2013

During a routine inspection

We spoke with four patients and one family member, as a carer. We spoke with staff, including the assistant practice manager and Dr Mohammed.

There was great deal of praise for the surgery and the doctors. Comments we heard from patients included, �can�t fault this surgery�, �� not a sausage factory� and �they take my worries seriously for example about X-rays for (my) small children�. One patient said, �the doctor is a nice man who listens�, another said,� I was in trouble and very depressed � (doctor�s words) � lifted me from my depression�.

There were systems in place to ensure that patients were protected from the risk of abuse.

Staff received appropriate professional development, training and appraisal.

There were systems in place to ensure that the quality of service that patients received was monitored.