Dr Mahmood & Partners

We carried out an announced focused inspection at Dr Mahmood and Partners on 10 and 15 July 2019. The key questions of safe, effective and well-led were evaluated at that time. The overall rating for the practice was inadequate and breaches of regulation were identified. The practice was placed into special measures. The full report and evidence table from the 2019 inspection can be found by selecting the ‘all reports’ link for Dr Mahmood and Partners on our website at .

At the inspection carried out in July 2019 the practice was rated as inadequate and placed into special measures because:

• Support systems and guidance for clinical and non-clinical staff were not sufficiently robust to guarantee staff and patient safety. Evidence to confirm that clinical staff had accessed required training relevant to their role was not in place.
• Systems for reporting, investigating and disseminating learning from incidents and complaints were not sufficiently embedded.
• Leadership and governance arrangements in the practice were not appropriate. Systems for timely communication of learning, including quality improvement activity, could not be demonstrated.
• Appropriate monitoring for patients with long-term conditions could not be assured, as Quality and Outcomes Framework (QOF) exception reporting rates for patients with long-term conditions and mental health conditions were significantly higher than local and national average in several areas.
• We were not assured that the leadership team was taking ownership and accountability for delivering safe care for patients.

This inspection, carried out on 4 March 2020, was an announced comprehensive inspection to review the practice’s response to the breaches of regulation identified at our previous inspection, and to review other improvements and changes made within the practice.

Requirement and warning notices were served at this time to compel the provider to rectify breaches in legal requirements in relation to Regulation 12(1) Safe Care and Treatment and Regulation 17(1) Good Governance.

At this inspection, carried out in March 2020, we found that the provider had made good progress in addressing many of the areas identified for action during our July 2019 inspection.

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

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

At this inspection we found:

• Significant improvements had been made in relation to systems for reporting, investigating and disseminating learning from incidents and complaints.
• Protocols and failsafe procedures had been developed for the management of correspondence and test results.
• Systems for monitoring and recording staff training and appraisal activity had been overhauled and improved.
• Quality improvement activity carried out in the practice was shared with relevant staff to improve outcomes for patients.
• Staff told us the leadership team was visible and approachable and staff felt supported to report concerns or make suggestions for improvements.
• National patient survey results had been analysed and an internal patient survey had been carried out which showed a high level of patient satisfaction.

The practice is rated as requires improvement for providing effective treatment to the population groups of people with long term conditions, families, children and young people, people experiencing poor mental health, and inadequate for providing effective treatment to working age people because:

• Targets in relation to cancer screening uptake and childhood immunisation had not been reached. We saw that uptake of cervical, breast and bowel screening were significantly below average, and had reduced since 2017/18.
• Monitoring of patients with long-term conditions and patients with mental health conditions could not be assured, as Quality and Outcomes Framework (QOF) achievement was below average in some cases, and exception reporting rates were significantly above local and national average in some cases.

Whilst we found no breaches of regulations, the areas where the provider should make improvement are:

• Improve the uptake of cancer screening at the practice, including breast, bowel and cervical screening.
• Improve the uptake of childhood immunisations.
• Improve outcomes for people with long-term conditions and mental health conditions.
• Maintain oversight of maintenance and health and safety activity carried out on their behalf by an external organisation

This service was placed in special measures in July 2019. Insufficient improvements have been made such that there remains a rating of inadequate for providing effective care to working age people. Therefore, the practice will remain in special measures. We will return to the practice to review the improvements made at a later date.

Dr Rosie Benneyworth BE BS BMed Sci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced new style focused inspection at Dr Mahmood and Partners on 10 and 15 July 2019 as part of our inspection programme. The practice had been previously inspected by the Care Quality Commission in February 2016. At that time the practice received a rating of good overall.

We decided to undertake an inspection of this service following our annual review of the information available to us. We visited on 10 July to inspect the key questions of effective, responsive and well-led. As a result of concerns identified during our inspection on 10 July, we returned to the practice on 15 July to also inspect the key area of safe.

Our judgement of the quality of care at this service is based 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 inadequate overall.

We have rated the practice as inadequate for providing safe services because:

• Systems for reporting, investigating and disseminating learning from incidents and complaints were not sufficiently embedded.
• There were significant gaps in relation to documented and recorded uptake of required training for staff.
• Systems and protocols for staff in relation to management of test results were not effective.

We have rated the practice as inadequate for providing effective services because:

• Quality improvement activity being carried out within the practice was not shared with relevant clinicians to improve patient outcomes.
• Appropriate monitoring for patients with long term conditions could not be assured, as Quality and Outcomes Framework (QOF) exception reporting rates for patients with long term conditions and mental health conditions were significantly higher than average in several areas.

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

• Systems for recording, analysing and learning from complaints were not sufficiently thorough.
• The provider was able to demonstrate that they had responded to the National GP Patient Survey results from 2018, and made some changes in relation to accessing services at the practice. However, the GP patient survey results from 2019 showed there were still some areas in which the practice needed to improve.

We have rated the practice as inadequate for providing well-led services because:

• Support systems and guidance for clinical and non-clinical staff were not sufficiently robust to guarantee staff and patient safety. Evidence to confirm that clinical staff had accessed training relevant to their role was not in place.
• Systems for reporting, investigating and disseminating learning from incidents and complaints were not sufficiently embedded.
• Leadership and governance arrangements in the practice were not appropriate. Systems for timely communication and dissemination of learning could not be demonstrated.
• GP patient survey results for 2019 showed areas where the practice was performing less well than local and national averages in some cases.
• We were not assured that the leadership team was taking ownership and accountability for delivering safe care for patients.

We found that:

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, the approach to reviewing, investigating and disseminating learning from incidents was insufficient or unclear.
• We saw evidence that the identified safeguarding lead in the practice had accessed training at the required level. However, there were significant gaps in relation to documentary evidence that clinical staff had completed training including infection prevention and control, health and safety and information governance. The provider was unable to demonstrate that all staff had accessed the appropriate level of safeguarding training.
• Systems of communication within the practice were not sufficiently robust. We saw that clinicians were working without access to regular meetings or means of leadership support.
• We were told that ‘buddy’ systems to cover for clinical staff were in place during their absence. However, we found that these were not consistently applied, resulting in delays in some cases in a clinical review of abnormal test results being carried out.
• Protocols to guide non-clinical staff in relation to responding to test results and other communication were not sufficiently clear. On 10 July we saw there was a backlog of tests requiring action without recourse to clinical guidance. Action had been taken to address this backlog by the time we returned on 15 July.
• There were gaps in relation to governance and leadership provision. The lead GP was on site for one day per week only, and the practice business manager was also only on site for part of the week.

However, we also found that:

• The practice had responded in part to patient survey results and a new telephone line had been installed. The practice was continuing to monitor patient satisfaction in relation to telephone access to the practice.
• The practice were aware of challenges within their practice population in regard to accessing screening services, and had plans to address these in order to improve uptake.

The areas where the provider must make improvements as they are in breach of regulations are:

• The service provider must ensure care and treatment is provided in a safe way to patients.
• The service provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review and improve the staff numbers deployed to provide for appropriate clinical cover to meet patient need.
• Review and improve systems for collating and monitoring staff training uptake.
• Review and improve guidance for staff in relation to managing incoming correspondence, and taking appropriate action in relation to abnormal test results.
• Improve processes in relation to recording and responding to complaints.
• Take steps to encourage and improve the rates of cancer screening uptake within the practive population. This includes for cervical, breast and bowel cancer. In addition, the provider should work to improve the percentage of patients with cancer, diagnosed within the preceding 15 months who have a patient review recorded as occurring within six months of the date of diagnosis.
• Increase the use of care planning templates to provide holistic proactive care to patients with complex health needs.
• Review and improve Quality and Outcomes Framework (QOF) exception reporting rates to enable patients to receive the appropriate care and treatment they require.
• Continue to review and take steps to improve patient experience in relation to accessing appointments.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made, so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

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