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Archived: Dr Simria Tanvir Good Also known as North Hyde Practice

Reports


Inspection carried out on 12 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Simria Tanvir (also known as North Hyde Practice) on 19 January 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 19 January 2016 inspection can be found by selecting the ‘all reports’ link for Dr Simria Tanvir on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 12 December 2016 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 19 January 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.

Our key findings were as follows:

  • The practice ensured that non-clinical staff undertaking chaperone duties completed relevant training
  • The practice had made improvements in the assessment of risks to patients, visitors and staff. There was evidence of completed risk assessments for health and safety, fire, and legionella. Fire safety arrangements now included a schedule of internal fire alarm testing and drills.
  • The practice had implemented a comprehensive cleaning schedule and log including the frequency of deep cleaning tasks.
  • Arrangements were in place for the monitoring of prescription stationery from when received and distributed within the practice.
  • The practice had a defibrillator for use in a medical emergency.
  • There was evidence of completed audit cycles to demonstrate quality improvement.
  • Processes were in place for the induction of locum GPs who were recruited to work at the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 19 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Simria Tanvir (also known as North Hyde Road Surgery) on 19 January 2016. Overall the practice is rated as requires Improvement.

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.
  • Some risks to patients were assessed and well managed, but risk monitoring was not well embedded across all areas of the practice to ensure patients were kept safe.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they felt staff were helpful, polite, caring and treated them with dignity and respect.

  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that 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 must make improvement are:

  • Ensure that risks are effectively assessed, monitored and mitigated across all areas of the practice. Including those for health & safety and not having a defibrillator for use in a medical emergency.

The areas where the provider should make improvement are:

  • Provide training for staff undertaking chaperone duties.

  • Review the environment cleaning schedule to provide clarity when cleaning tasks have been completed.

  • Review the systems in place for the management of prescription forms to ensure they meet recommended guidance.

  • Conduct a programme of complete cycle audits to demonstrate quality and improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 27 August 2014

During a routine inspection

The North Hyde Practice (Dr Simria Tanvir)  provides NHS services to 3150 patients within the Hillingdon Clinical Commissioning Group (CCG), who provide a service to the London borough of Hillingdon.  Census data shows that there is an increasing population and the area has a higher than average proportion of black and minority ethnic groups. Life expectancy is 6.6 years lower than the national average for men and 4.7 years lower for women in the most deprived areas of Hillingdon. The proportion of people below 40 years of age is above the England average and it is below average for those over 40 years.

The North Hyde Practice operates from its own premises which include three consulting rooms, a conference room, administration rooms and patient waiting area. The practice is an individual GP practice which employs locum doctors to provide a full service to patients.

We carried out an inspection of the practice on 27 August 2014. As part of the inspection we spoke with the GP, the practice nurse, facilities manager, administration staff and patients awaiting their appointment. We also received feedback through Care Quality Commission (CQC) comment cards which were available for patients to complete prior to the visit.

The practice had systems to monitor safety and staff reported and learned from incidents. However, improvements were needed in the consistency of recording events and the frequency of submitting data to the Quality and Outcomes Framework (QOF).

We found that some clinical audits had been completed but there was no evidence of a completed audit cycle.  Safeguarding procedures were in place and staff had received the appropriate training. We found an open and transparent culture amongst staff. There were arrangements in place to deal with medical emergencies and the practice had an up to date business continuity plan.

The practice had a Patient Participation Group (PPG) which met four times a year and was involved in the implementation of an annual patient survey. Patients had mixed views about accessing appointments with some saying it was difficult to contact the practice during the extended closing hours over lunch time.

We found improvements were needed to the way that the practice responded to those patients who did not speak English. The practice provided a translation service through staff translating and the use of a telephone translation service but written literature was only available in English.

The practice did not fully support patients at a time of bereavement; there was no literature or signposting to other services that may be of help to people.

The practice was able to meet the needs of the different population groups who accessed the service. It offered a range of services and worked well with other health professionals to provide appropriate referrals.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.