Archived: Ejaz Medical Centre

We carried out an announced comprehensive inspection at Ejaz Medical Centre on 9 December 2019 as part of our inspection programme.

At the last inspection in March 2019 we rated the practice as inadequate for providing safe, and well-led services because:

• The practice had not assessed and managed all risks such as those related to health and safety.
• The provider did not stock medicines for all emergency situations, a risk assessment was in place to support the decision making. However, the risk assessment was not comprehensive and did not provide a clear rationale for the decision and how a situation would be managed if it was required.
• The provider did not have an effective governance process to identify and mitigate all risks and to ensure a consistent approach to care delivery. For example, there was a lack of leadership oversight and an effective governance framework to monitor the quality and safety of the service provided.

We rated the practice as requires improvement for providing effective, caring and responsive services because:

• Cancer screening achievement including cervical cytology was below local and national averages.

• Staff treated patients with kindness, respect and compassion. However, feedback from the national GP patient survey showed some areas was below local and national averages and there was no evidence that the practice had reviewed and acted on the feedback.

• The practice was unable to demonstrate how they were responding to all findings of the national GP patient survey including patients overall experience at the practice and patient satisfaction with the appointments.

At this inspection, we found that the provider had satisfactorily addressed many of the areas identified previously. However, there were areas that required further improvement.

We based our judgement of the quality of care at this service is 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.
• Consider appropriateness of hand bells in comparison to a smoke detector or fire alarm to raise awareness in the event of serious fire.

We have rated the service as requires improvement overall including all population groups.

We rated the service requires improvement for providing effective, caring and responsive care.

We found that:

• The services achievement for cervical cytology was below local and national averages.
• Data provided by the practice post inspection for childhood immunisation demonstrated that they had achieved over 80% uptake but this was still below the minimum 90% target achievement rate.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. However, national patient survey feedback was below local and national averages.
• The practice was taking action to improve access to meet patient needs. However, national patient survey feedback was significantly below local and national averages and had deteriorated since our previous inspection. This did not suggest that patients always had access to timely care.

We rated the practice good for providing safe and well-led services.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The service was aware of the areas requiring further improvements such as childhood immunisations, cervical cytology and feedback on the national patient survey and was able to demonstrate actions being taken to achieve improvements.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found no breaches of regulations, the provider should:

• Continue to respond to findings from the national patient survey to achieve improvements.

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

We carried out an announced comprehensive inspection of Druid Group on 13 March 2019 as part of our inspection programme. The service had registered within the last 12 months with the CQC.

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 inadequate overall

We rated the practice as inadequate for providing safe and well led service because:

• The practice had not assessed and managed all risks such as those related to health and safety.
• The provider did not stock medicines for all emergency situations, a risk assessment was in place to support the decision making. However, the risk assessment was not comprehensive and did not provide a clear rationale for the decision and how a situation would be managed if it was required.
• The provider did not have an effective governance process to identify and mitigate all risks and to ensure a consistent approach to care delivery. For example, there was a lack of leadership oversight and an effective governance framework to monitor the quality and safety of the service provided.

We rated the practice as requires improvement for providing effective, caring and responsive services because:

• Cancer screening achievement including cervical cytology was below local and national averages.
• Staff treated patients with kindness, respect and compassion. However, feedback from the national GP patient survey showed some areas was below local and national averages and there was no evidence that the practice had reviewed and acted on the feedback.
• The practice was unable to demonstrate how they were responding to all findings of the national GP patient survey including patients overall experience at the practice and patient satisfaction with the appointments.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients
• 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:

• Improve the identification of carers to enable this group of patients to access the care and support they need.
• Review processes to ensure cancer screening achievements are in-line with local and national averages.
• Review possible causes in the discrepancy between the practice's childhood immunisation figures to that of published data.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate 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 service 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 by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service 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