You are here

Dr Touseef Safdar Requires improvement

Reports


Inspection carried out on 17 December 2019

During a routine inspection

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 carried out on 2 February 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Touseef Safdars practice, Central Clinic, on 14 January 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment

Regulation 11 HSCA (RA) Regulations 2014 Need for consent

Regulation 17 HSCA (RA) Regulations 2014 Good governance

We undertook a focused inspection on 2 February 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Touseef Safdar on our website at www.cqc.org.uk.

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

  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse. Staff were aware of the process and their responsibilities to raise and report concerns, incidents and near misses. We saw that significant events were regularly discussed with staff during practice meetings.

  • Staff assessed needs and delivered care in line with current evidence based guidance. A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. Results were circulated and discussed in the practice.

  • The practice worked with other service providers to meet patient’s needs and manage those of patients with complex needs.

  • The practice had arrangements in place to respond to emergencies and major incidents.

  • Staff files demonstrated that appropriate recruitment checks had been undertaken prior to employment.

  • There were some arrangements for identifying and recording and managing risks, issues and implementing mitigating actions. The risk assessments for fire and legionella contained actions for completion however there were no timeframes or action owners listed on the action plans.

  • The management team encouraged a culture of openness and honesty and staff at all levels were actively encouraged to raise concerns. The practice also sought feedback from staff through an annual staff survey, staff said they felt supported and part of a close team.

The areas where the provider should make improvement are:

  • Keep records to support that risks associated with premises and infection control are adequately managed and to reflect the cleaning of the environment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 14 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected Dr Touseef Safdar, Central Clinic, Hall Street, Dudley, on 14 January 2015 as part of a comprehensive inspection. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well-led services. The areas for improvements that led to these ratings also applied to all of the six population groups that we inspected and which are also rated as requires improvement. These were, people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health. We rated the practice good for providing an effective, caring and responsive service.

Our key findings were as follows:

  • The systems in place to ensure patients received a safe service were not robust.

  • The practice did not have effective systems to engage and work in collaboration with other services and health care professionals in the management of patients with complex and long term conditions. The system in place for reviewing patients test results and referrals was not clear. The lead GP did not assess mental capacity in accordance with the requirements of the Mental Capacity Act (2005).

  • Patients were complimentary about the staff at the practice and said they were caring, listened and gave them sufficient time to discuss their concerns.

  • The practice was responsive to the needs of the practice population. There were services aimed at specific patient groups.

  • The leadership structure in place was not clearly defined. Staff spoken with were committed to providing a high quality service. However, they described the overall leadership culture as lacking support and direction.

There were particular areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Operate effective recruitment procedures and ensure that the information required under current legislation is available in respect of all staff employed to work at the practice.

  • Improve engagement and collaboration with other services and health care professionals in the management of patients with complex and long term conditions.

  • Assess mental capacity in accordance with the requirements of the Mental Capacity Act (2005).

  • Have a clear procedure in place for reviewing patients test results and referrals to ensure they are reviewed in a timely manner.

  • Improve the governance arrangements at the practice by assessing, monitoring and mitigating the risks relating to the health, safety and welfare of service users and others. Ensure sensitive patient information is maintained securely and available only to relevant professionals. Seek and act on feedback from staff, for the purposes of continually evaluating and improving the service.

In addition the provider should:

  • Ensure there are systems in place to ensure important information is shared with all staff such as patient safety alerts and the business continuity plan.

  • Have clear processes in place for staff to follow so that patients with no fixed address or those requiring temporary registration can be seen or be registered at the practice.

  • Proactively identify and support those with caring responsibilities.

  • Ensure processes are in place to assure themselves that regular cleaning of the general environment and equipment used for patients care and treatment has been undertaken to an appropriate standard.

  • Ensure records are in place to evidence that clinical staff have relevant vaccinations appropriate to their role in line with the General Medical Council’s Good Medical Practice (GMP) guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 5 September 2014

During an inspection to make sure that the improvements required had been made

At our last inspection in February 2014, we found that patients were not adequately protected from the risk of abuse because the provider had taken some reasonable steps to identify the possibility of abuse and prevent abuse from happening. We also found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service. We set compliance actions and told the provider to improve.

The purpose of this inspection was to see if improvements had been made since our last inspection in February 2014. We gave the provider short notice of our inspection so that any disruption to patient's care and treatment were minimised. During the inspection we spoke with four members of staff, this included the practice manager, the lead GP (who was also the provider), the practice nurse and a receptionist.

We saw that the provider had made some changes to improve the service and to improve the quality of the care. However, more assessments were required so that the provider could be assured that this was being delivered.

Inspection carried out on 10 February 2014

During a routine inspection

On the day of our inspection we spoke with six patients and five members of staff. One patient said, �The nurse is nice and the reception staff are always polite." Most of the patients we spoke with said they were unable to obtain appointments at a time to suit their needs. However, all the patients we spoke with said they felt the quality of care they received was good.

We saw that patients were treated with dignity and respect. One patient told us, �The staff are well versed in discretion." We saw that patients experienced care and treatment that met their needs.

Patients told us and we saw that care was delivered in a clean environment. Staff required training in safeguarding of vulnerable adults but were aware of whom to report concerns to.

Improvements were required to the quality monitoring systems to assess and monitor the quality of service that patients received. Improvements in patient engagement and management of risks were required.