Archived: Dr Gul Mohammad Khan Also known as Aleeshan Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Dr Gul Mohammad Khan on 10 June 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective, and well led services. It was good for providing caring and responsive services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Although some audits had been carried out, these were single cycle audits and we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Urgent appointments were usually available on the day they were requested. Routine appointments could be made several weeks in advance.
• The practice staff met informally every day. More formal meetings were held monthly and brief minutes were kept.
• The GP had sought feedback from patients as part of their appraisal process.
• All staff at the practice spoke more than one language to meet the needs of the practice population.

The areas where the provider must make improvements are:

• Ensure young people under 16 who have the legal capacity to consent are treated with dignity and privacy and given independence. These young people must be treated with consideration and respect.
• Ensure consent is gained from the relevant person prior to care or treatment taking place. If a person over the age of 16 is unable to give such consent because they lack capacity to do so, the provider must act in accordance with the Mental Capacity Act 2005.
• Ensure all staff have completed mandatory training such as fire safety training and basic life support, and that this training is updated regularly.
• Ensure standards for the cleaning of the practice are set out and adhered to, including identifying cleaning tasks that should be carried out daily. Staff, including the infection control lead, must be trained in the prevention and control of infection.
• Ensure all staff have received training in safeguarding children and vulnerable adults to the appropriate level and that this training is updated at appropriate intervals.
• Ensure there are systems in place to regularly monitor and assess aspects of the practice. This includes completing full clinical audit cycles and performing regular checks to ensure all medicines and equipment are within their expiry dates.
• Ensure that recruitment procedures are in place so that only suitable people are employed. Ensure required information, such as a full work history and identification is kept for all staff and all relevant pre-employment checks are carried out.

In addition the provider should:

• Set up a register so all patients with a learning disability can be identified.
• Formalise meetings in order to evidence information such as significant events have been discussed with all relevant staff.
• Improve the business continuity plan so it includes accurate information about the action to take in the event of an emergency.
• Provide the practice manager with the support and training they require.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice