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Dr M Umar & Dr H Sadique Good Also known as Nelson Medical Practice

Inspection Summary


Overall summary & rating

Good

Updated 3 February 2017

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Dr M Umar & Dr H Sadique for areas within the key question well-led. This review was completed on 24 December 2016.

Upon review of the documentation provided by the practice, we found the practice to be good in providing well-led services. Overall, the practice is rated as good.

CQC previously inspected the practice on 19 January 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, the key question well-led was identified as ‘requires improvement’. Whilst CQC did not issue any requirement notices, but the practice was advised they should make improvements in a number of areas including:

  • Implementing a system to periodically review the effectiveness and impact of changes implemented as a result of significant event analysis.
  • Ensuring that all staff know the location of the emergency medicines.
  • Implementing a system to review at intervals the contractual obligations for the building environment and equipment with the property landlord so that potential risks to safety are mitigated.
  • Reviewing and developing the practice’s communication strategies so that information about the practice, its policies and procedures and specific health conditions are available to people in different languages and in different formats.
  • Continuing to review telephone and appointment access to seek further improvements to meet patient demand following the GP survey results.
  • Improving governance arrangements by recording a business plan with priorities and strategies to provide focus and clarity on the development of the service and progress against the practice’s aims and objectives.
  • Implementing a system of regular planned performance monitoring whereby significant events, complaints, updated clinical guidance, patient feedback and the practice’s progress in meeting the Quality and Outcomes Framework (QOF) is undertaken.

During this review in December 2016, we found that the practice had addressed all the areas of concern from the inspection in January 2016.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 3 February 2017

The practice is rated as good for providing safe services.

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website:

http://www.cqc.org.uk/search/services/doctors-gps

Effective

Good

Updated 3 February 2017

The practice is rated as good for providing effective services.

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website:

http://www.cqc.org.uk/search/services/doctors-gps

Caring

Good

Updated 3 February 2017

The practice is rated as good for providing caring services.

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website:

http://www.cqc.org.uk/search/services/doctors-gps

Responsive

Good

Updated 3 February 2017

The practice is rated as good for providing responsive services.

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website:

http://www.cqc.org.uk/search/services/doctors-gps

Well-led

Good

Updated 3 February 2017

The practice is rated as good for providing well-led services.

At the inspection in January 2016, the practice was rated as requires improvement for well-led services and a number of areas were identified where the practice should make improvements. This included improving the governance arrangements within the practice to include:

  • Reviewing actions and learning from significant events
  • Ensuring all staff could locate the emergency medicines
  • Reviewing arrangements for checking that emergency equipment was safe for use
  • Improving patient information in languages appropriate to the population
  • Developing a business plan
  • Improving responsiveness to patient feedback

During this desk top review in December 2016, we found that the practice had acted on these recommendations and made improvements to their documentation and governance arrangements to improve patient care.

Evidence provided to CQC for this review included:

  • Copies of minutes of practice and integrated neighbourhood team meetings, including significant event and complaint reviews and monitoring patient outcomes.
  • Copies of the 2015 and 2016 patient surveys and actions taken to improve the patient experience.
  • Friends and family test data for the practice for the last 12 months.
  • Copies of leaflets made available for patients in Urdu.
  • Evidence of regular checks being carried out on the defibrillator and that the location of emergency medication had been discussed with all staff.
  • A copy of the business plan prepared by the practice.
  • Improved staffing including recruiting a new clinical pharmacist
  • A summary of improvement areas by the practice manager

We also reviewed Quality and Outcome Framework (QOF) data (QOF is a system intended to improve the quality of general practice and reward good practice) for 2015/16 and GP survey results which were published in July 2016. The data and results showed there were improvements in these areas also.

Checks on specific services

People with long term conditions

Good

Updated 3 February 2017

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

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website

http://www.cqc.org.uk/search/services/doctors-gps

Families, children and young people

Good

Updated 3 February 2017

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

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website

http://www.cqc.org.uk/search/services/doctors-gps

Older people

Good

Updated 3 February 2017

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

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website 

http://www.cqc.org.uk/search/services/doctors-gps

Working age people (including those recently retired and students)

Good

Updated 3 February 2017

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

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website:

http://www.cqc.org.uk/search/services/doctors-gps

People experiencing poor mental health (including people with dementia)

Good

Updated 3 February 2017

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

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website

http://www.cqc.org.uk/search/services/doctors-gps

People whose circumstances may make them vulnerable

Good

Updated 3 February 2017

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

This rating was given following the comprehensive inspection in January 2016. A copy of the full report following this inspection is available on our website:

http://www.cqc.org.uk/search/services/doctors-gps