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Dr Touseef Safdar Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 February 2020

We carried out an inspection of this service on 17 December 2019 following our annual regulatory review of the information available to us including information provided by the practice.

Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

Are services at this location safe?

Are services at this location effective?

Are services at this location caring?

Are services at this location responsive?

Are services at this location well-led?

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.


We have rated this practice as requires improvement overall and requires improvement for the population groups of working age people (including those recently retired and students) and people experiencing poor mental health (including dementia).

We rated the practice as requires improvement for providing safe services because:

  • Non clinical staff in patient facing roles had not been appropriately risk assessed or had a review of their immunisation needs against possible infections.

We rated the practice as requires improvement for providing effective services because:

  • Measures taken to improve the practice’s uptake of the national screening programme for cervical cancer to date had not been effective. As a result, the practice’s rate for uptake was significantly below the national target.
  • Despite steps taken to increase the outcomes for mental health indicators, the practice were still below national averages and this could be further improved.

We rated the practice as requires improvement for providing caring services because:

  • Patient satisfaction rates were significantly lower than local and national averages for data indicators relating to the caring key question. Actions taken in response to this by the practice had not had an impact on levels of patient satisfaction in these areas.

We also rated the practice as good for providing responsive and well-led services because:

  • There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment that met their needs.
  • Patients needs were assessed and care and treatment was delivered in line with current legislation.
  • Risks to patients were assessed and well managed.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider should make improvements:

  • Develop an effective system to risk assess, record and monitor the immunisation status of staff members in line with best practice.
  • Continue work to increase the uptake for cervical, breast and bowel screening.
  • Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
  • Continue work to improve performance and outcomes relating to diabetes.
  • Review procedures in place to demonstrate improved outcomes for patients where satisfaction levels are still low.
  • Continue to work on the uptake of online access for patients.
  • Continue work to identify and support carers registered in the practice.
  • Complete sepsis training for all staff in the practice.
  • Continue with steps to engage with a patient participation group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Requires improvement

Effective

Requires improvement

Caring

Requires improvement

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Good