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Archived: Umar Medical Centre Inadequate Also known as Dr A Alam & Dr S Adam

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Inadequate

Updated 11 October 2018

We carried out an announced comprehensive inspection at Umar Medical Centre on 7 March 2018. The overall rating for the practice was inadequate and we issued warning notices for breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and Treatment) and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). The full comprehensive report following the inspection in March 2018 can be found on our website here: https://www.cqc.org.uk/location/1-583513367/reports.

This inspection was an unannounced focused inspection carried out on 31 July 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches identified within the warning notices.

At this inspection we found:

  • The practice had made improvements to systems and processes to ensure that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • A new protocol had been implemented to ensure incoming correspondence to the practice was managed effectively and in a timely manner. Staff we spoke with were aware of this protocol and their responsibilities relating to it and we saw evidence the provider had carried out an audit to ensure the new process was working as intended.
  • While risk assessments had been completed around fire and legionella, mitigating actions identified as a result had not been undertaken. The same was found in relation to the infection prevention and control audit recently completed.
  • While recruitment checks relating to locum GPs employed by the practice had improved, we found gaps in the pre-employment checks completed for three new permanent members of staff.
  • The practice had made improvements around oversight of staff training and development needs and had produced an appraisal schedule to ensure staff received an appropriate appraisal in a timely manner.

At our previous inspection on 7 March 2018, we rated the practice as inadequate and placed the service into special measures. As per our published inspection methodology, a further full comprehensive inspection visit will be carried out within three months to monitor the work the practice has started to produce the required improvements to the service.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Inadequate

Updated 11 October 2018

At our previous inspection on 7 March 2018, we rated the practice as inadequate for providing safe services. Findings identified as breaching regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment and Good Governance respectively) included:

  • Inadequate systems to manage incoming correspondence.
  • Inadequate systems and processes to manage, assess and mitigate risks, including those related to the practice premises, recruitment and infection prevention and control.
  • The system for identifying, recording, investigating and monitoring significant events was not adequate.

There had been some improvements with these arrangements when we undertook a follow up inspection on 31 July 2018, although further improvements were still required.

Safety systems and processes

The practice had begun to implement systems to keep people safe, although these were not yet sufficiently embedded into practice.

  • At our previous inspection in March 2018, we saw that recruitment checks for locum GPs employed by the practice had not been thorough. At this inspection, we found recruitment checks for locums had improved, but checks for three new permanently employed staff members, including a practice nurse were lacking. Shortly after our visit the practice sent further evidence to demonstrate that recruitment checks had been undertaken for these staff members since our visit, including Disclosure and Barring Service (DBS) checks. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • An infection prevention and control audit had been completed since our previous inspection. However, actions identified as a result in order to further mitigate risks had yet to be put in place.
  • Similarly, risks relating to fire safety and legionella (legionella is a term for a particular bacterium which can contaminate water systems in buildings) had been comprehensively assessed since our previous visit, but mitigating actions identified had not been implemented at the time of our most recent inspection.

Information to deliver safe care and treatment

The practice had improved processes to ensure staff had the information they needed to deliver safe care and treatment to patients.

At our previous inspection in March 2018, we found the practice did not have thorough systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. For example, in March 2018 the practice did not have a documented procedure for the management of incoming correspondence. At our most recent inspection, we saw that a documented protocol for this had been implemented, staff were aware of their responsibilities in relation to it, and the new process had been audited so that the provider could be assured it was working effectively.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • A new significant event analysis policy had been put in place in May 2018 and staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.

Effective

Inadequate

Updated 11 October 2018

At our previous inspection on 7 March 2018, we rated the practice as inadequate for providing effective services. Findings identified as breaching regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment and Good Governance respectively) included a lack of managerial oversight of unmet training needs amongst non-clinical staff and the potential for poorly coordinated care as a result of poor information flow within the practice.

There had been improvements with these arrangements when we undertook a follow up inspection on 31 July 2018.

Effective staffing

During our inspection in March 2018 we identified the practice lacked an up to date understanding of the learning needs of staff. There was no systematic approach to ensuring non-clinical staff had access to appraisals in order to monitor performance, development and training needs. We saw the practice had put measures in place to improve this when we re-inspected in July 2018. Appraisals for four staff had been completed since our previous inspection, and an appraisal schedule produced to ensure all other staff received their appraisal in a timely manner.

Coordinating care and treatment

At our previous inspection in March 2018 we found a lack of clarity around the management of correspondence from secondary care presented the risk of inefficient and disjointed information flow within the practice with regards to the treatment needs of patients. In July 2018 we found this had improved, with clear policies and protocols implemented. Staff were clear regarding their responsibilities in relation to these and the provider had completed an audit of the new process to assure themselves it was working as intended.

Caring

Requires improvement

Responsive

Inadequate

Well-led

Inadequate

Updated 11 October 2018

At our previous inspection on 7 March 2018, we rated the practice as inadequate for providing well led services. Findings identified as breaching regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance) included evidence the governance structure did not provide adequate systems and processes to ensure safe and effective care.

There had been some improvements with these arrangements when we undertook a follow up inspection on 31 July 2018, although further improvements were still required.

Governance arrangements

The practice had improved the implementation of clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management had been set out and were in the process of being embedded into practice.
  • Staff were clear on their roles and accountabilities including in respect of newly implemented protocols around managing incoming correspondence and any changes resulting from significant event analysis.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

The practice had begun to put processes in place for managing risks, issues and performance. However, these were not yet sufficiently embedded.

  • There was a process to identify risks, including risks to patient safety. However, the practice was unable to demonstrate timely action had been taken as a result in order to further mitigate them.
  • The practice had some processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Inadequate

Updated 14 May 2018

Families, children and young people

Inadequate

Updated 14 May 2018

Older people

Inadequate

Updated 14 May 2018

Working age people (including those recently retired and students)

Inadequate

Updated 14 May 2018

People experiencing poor mental health (including people with dementia)

Inadequate

Updated 14 May 2018

People whose circumstances may make them vulnerable

Inadequate

Updated 14 May 2018