You are here

Teehey Lane Medical Centre - Dr. M Salahuddin Good

All reports

Inspection report

Date of Inspection: 8 January 2014
Date of Publication: 4 February 2014
Inspection Report published 04 February 2014 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We carried out a visit on 8 January 2014, observed how people were being cared for, talked with people who use the service and talked with staff. We talked with commissioners of services and were accompanied by a specialist advisor.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

The service had a patient participation group (PPG) that had been operating for just over twelve months. This group was made up of volunteer patients and staff from the service who met to discuss the services on offer and how improvements could be made for the benefit of the local patient population. The patient participation group had met once in the last twelve months although four meetings had been planned. We met with two patients who were members of the PPG. They said that they were involved in the last survey and in discussions around the recent refurbishment and all suggestions made had been implemented. They said that they were working with the manager and practice manager to ensure more regular meetings were held to provide greater continuity.

We saw the results of the last patient survey 2012/2013. Overall the results were positive and showed higher than national average results in several areas such as appointment satisfaction, seeing practitioner of choice, opening hours and telephone access. Where shortfalls had been identified, for example, around modernising the waiting area and patient parking, an action plan had been drawn up in response that showed the changes made/planned to the service provided.

Details on how to make any comments or complaints were contained in the information leaflet provided to patients. The procedure was not displayed in the waiting area. The practice manager reported that this was normally on display but had had not been replaced following the refurbishment. They advised they would address this without delay. The provider may find it useful to note that complaints information contained within the practice information booklet did not have details of the Care Quality Commission, to which patients could comment about the operation of the service. Records and a discussion with the practice manager indicated that complaints were documented and dealt with appropriately. We also found that any action needed following the investigation into a complaint had been undertaken.

The manager reported that practice meetings took place to discuss new information and plan ahead. We saw the record of the last meeting in September 2013 which included discussions around changes to practice and the management of complex care needs. Informal daily meetings also took place where clinical staff were able to discuss patients with complex needs, any new information and changes needed.

We saw that records were kept of any adverse events or incidents including actions taken. These records showed that no events had been recorded within the last twelve months. The provider may find it useful to note that a procedure for identifying what constituted an adverse event or incident so that all staff were aware to report such matters and the action to be taken following this was not available.

We found that a number of clinical and non-clinical audits were undertaken to ensure that the service met standards and operated safely and effectively.

The service participated in the quality and outcomes framework system (QOF) which is an annual, voluntary performance assessment system used by the NHS to measure GP’s performance in a number of clinical and non-clinical areas. We spoke with one GP who told us about the systems in place to monitor services and record performance against the quality and outcomes framework.