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Dr Mohan S Saini Good Also known as Soho Medical Services

Inspection Summary


Overall summary & rating

Good

Updated 3 May 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mohan Saini practice on 25 February 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patient Group Directions (PGD) had been adopted by the practice to allow nurses to administer medicines in line with legislation.
  • The practice had a system for the management of clinical waste, however on the day of the inspection it was not stored securely.
  • Document management processes were not effective, staff were unable to identify where they would locate some of the policies and procedures.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff had received training appropriate to their roles.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The GP had developed tools to support patients experiencing poor mental health. medication review template and a patient information template to educate and support patients.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice including;

The practice had a higher than average number of young patients. The GP had developed a face book page that they updated and monitored to improve communication with this population group. The page included information on health lifestyle and developments to services in the practice that would affect them. There were 400 followers.

The areas where the provider should make improvement are:

  • Implement a robust system for managing policies and procedures.
  • Ensure clinical waste is managed and stored safely.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 3 May 2016

The practice is rated as good for providing safe services.

  • There was and effective system in place for reporting and recording significant events.

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses.

  • Risks to patients who used services were assessed.

  • On the day of the inspection, clinical waste was not managed effectively as there was unsecure storage.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse

Effective

Good

Updated 3 May 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average for the locality and compared to the national average.

  • 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 multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 3 May 2016

The practice is rated as good for providing caring services.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • 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.

  • Results from the national GP patient survey January 2016, were in line with local and national averages

Responsive

Good

Updated 3 May 2016

The practice is rated as good for providing responsive services.

  • 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 had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

  • The practice had a higher than average younger age population group and had developed systems to enable them to communicate with this group more effectively.

  • The GP had produced a Mental Health review template to ensure a holistic assessment of the patients’ needs

  • The GP had produced a medication review template and a patient information template to educate and support patients to manage their medicines.

Well-led

Good

Updated 3 May 2016

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this.

  • There was a clear leadership structure and staff felt supported by management.

  • The practice had a number of policies and procedures to govern activity and held regular practice meetings. However the system for document management was not robust.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

  • The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

  • The practice sought feedback from staff and patients, which it acted on. The patient participation group was active.

Checks on specific services

Older people

Good

Updated 3 May 2016

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 urgent appointments for those with enhanced needs.

  • Home visits were available for older patients and patients who would benefit from these.

  • The GP had developed a medication review template and patient information template to support and educate patients taking multiple medicines.

  • An annual review to check their health needs was provided

People with long term conditions

Good

Updated 3 May 2016

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.

  • The GP had developed a medication review template and patient information template to support and educate patients taking multiple medicines.

  • 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 those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

  • A thrice weekly walk in clinic for health checks was available.

Families, children and young people

Good

Updated 3 May 2016

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 relatively high 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.

  • 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.

  • A Facebook page had been developed for the surgery, with 400 followers , this is regularly updated by the GP.

  • A thrice weekly walk in clinic for health checks was available.

  • Childhood immunisation rates for the vaccinations given were higher than the CCG/national averages. For example, childhood immunisation rates for the vaccinations given to under two year olds ranged from 89.7% to 94.8% compared to the CCG average which ranged from 41.2% to 92.2%. Immunisation rates for five year olds ranged from 84.2% to 97.4% compared to the CCG average which ranged from 87.1% to 94.4%.

Working age people (including those recently retired and students)

Good

Updated 3 May 2016

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.

  • There were extended opening hours throughout the week and a telephone triage service available early mornings and evenings which would benefit working patients.

The practice offered health promotion and NHS health checks for people aged 40 to 74 years of age.

People whose circumstances may make them vulnerable

Good

Updated 3 May 2016

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

  • The practice held a register of patients with a learning disability.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.

  • The practice informed vulnerable patients about how to access various 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 3 May 2016

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

  • The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.

  • The practice carried out advance care planning for patients with dementia.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • Percentage for mental health related indicators was 100% of QOF compared with the CCG average of 89% and national average of 93.8%.

  • The GP had developed a medication review template and patient information template to support and educate patients taking multiple medicines.

  • The GP had reviewed the services provided to patients experiencing poor mental health and as a result the practice had developed a review template to ensure a holistic assessment of the patients’ needs.