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Dr Sajid Mehmood Good Also known as Neville Road Surgery

Inspection Summary


Overall summary & rating

Good

Updated 24 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sajid Mehmood’s practice on 07 June 2016. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from internal and external incidents were maximised.
  • Feedback from patients about their care showed that 98% of patients stating they had confidence and trust in the last GP they saw.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
  • The practice had a clear vision which had quality and safety as its top priority.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had clinical and managerial leadership and governance arrangements in place.

However there were areas of practice where the provider should make improvements:

  • Ensure complaints forms are readily available to patients.
  • Consider a documented business plan to assist with the management and strategic development of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 24 February 2017

The practice is rated as good for providing safe services.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
  • There was an effective system in place for reporting and recording significant events
  • Lessons learnt were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received appropriate support, information and a written apology. They were told about any actions to improve processes to prevent the same thing happening again. However, the practice should ensure complaint forms are readily available to patients.
  • The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed.

Effective

Good

Updated 24 February 2017

The practice is rated as good for providing effective services.

  • Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.
  • We also saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were generally above average compared to local and national averages. For example, 92% of patients diagnosed with dementia had received a face-to-face review of their care in the previous 12 months, compared to 81% in the local Clinical Commissioning Group area the England average of 84%
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 24 February 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed that patients reported they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • 86% of patients described their overall experience of the practice as good or fairly good, compared to the local CCG average of 79% and the national average of 85%.
  • 92% of patients said they were treated with care and concern the last time they saw a GP, compared to the CCG average of 80% and the national average of 85%.
  • Feedback from the 32 completed CQC comment cards was consistently positive. Patients told us they were impressed by the attitude and approach of the staff.

  • 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 24 February 2017

The practice is rated as good for providing responsive services.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.
  • 94% of patients said the receptionist at the practice were helpful, compared with the CCG average of 84% and a national average of 87%.
  • 79% of patients described their experience of making an appointment as good, compared to the CCG average of 66% and national average of 73%.
  • Patients can access appointments and services in a way and at a time that suits them.
  • The practice had good facilities and was equipped to treat patients and meet their needs.
  • Information about how to complain was available by asking reception staff but was not available in the waiting area. The practice responded appropriately when issues were raised. Learning from complaints was shared with staff.

Well-led

Good

Updated 24 February 2017

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

  • The practice had a clear vision to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it. However, the practice should consider a documented business plan to assist with the management and strategic development of the practice.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice had of policies and procedures in place to govern activity and held regular management meetings.
  • The provider was aware of and complied with the requirements of the duty of candour, a culture of openness and honesty was encouraged.
  • The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.
  • There was a focus on continuous learning and improvement at all levels, with positive engagement with staff.
  • The practice gathered feedback from patients, and it had a patient participation group which influenced practice development.
Checks on specific services

People with long term conditions

Good

Updated 24 February 2017

The practice is rated as good for the care of people with long-term conditions.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • 99% of the patients on the diabetes register had received an influenza immunization in the period from 1 August to 31 March 2015, compared to 93% within the CCG and the national average of 94%.
  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met.
  • For patients with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 24 February 2017

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.
  • Immunisation rates were comparable with local CCG and national averages for all standard childhood immunisations.
  • Patients told us that children and young people were treated in an age appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • Latest results show that 79% of women aged between 25 - 64 years of age had been performed a cervical screening test in the preceding five years, which was above the CCG average of 69% and the national average of 74%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.

Older people

Good

Updated 24 February 2017

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice register shows that approximately 8% of patients were aged over 65 years at the time of our inspection.
  • Older people had access to targeted immunisations such as the flu vaccine.
  • Patients over 75 years of age had a named GP and patients discharged from hospital were contacted to check on their situation and health condition.

Working age people (including those recently retired and students)

Good

Updated 24 February 2017

The practice is rated as good for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.
  • 48% of patients aged 60 to 69 years had been screened for bowel cancer in the last 30 months compared to 51% locally and 58% nationally.
  • 65% of female patients aged 50 to 70 years had been screened for breast cancer in the last three years compared to 71% locally and 72% nationally.
  • The practice had added telephone consultations for patients unable to attend the surgery.
  • There were additional appointments available to meet the needs of working age patients, where the practice offered extended opening hours until 7.30pm on Tuesday evenings.

People experiencing poor mental health (including people with dementia)

Good

Updated 24 February 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • 92% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, compared to the CCG average of 81% and the national average of 84%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice had told patients experiencing poor mental health about how to access support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended A&E where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 24 February 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice informed vulnerable patients about how to access support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children.
  • Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 62 patients as carers (approximately 2% of the practice list).