The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Shada Parveen Also known as Maybury Surgery

Overall: Inadequate read more about inspection ratings

The Maybury Surgery, Alpha Road, Woking, Surrey, GU22 8HF (01483) 728757

Provided and run by:
Dr Shada Parveen

All Inspections

26 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shada Parveen (also known as The Maybury Surgery) on 15 November 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. We carried out a focused inspection on 26 April 2017 to ensure that the practice had complied with legal requirements. We reviewed the safe, effective and well led domains and found these still to be inadequate. Therefore the practice remained in special measures. The full comprehensive report on the 15 November 2016 and the focused report on the 26 April 2017 inspection can be found by selecting the ‘all reports’ link for Dr Shada Parveen on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection undertaken on 26 September 2017, following the period of special measures. The practice has failed to adequately improve and overall the practice remains rated as inadequate.

Our key findings at this inspection in September 2017 were as follows:

  • We received positive feedback from patients who said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • There was an effective system for identifying, risks and issues. However it was not always clearly recorded when mitigating actions had been completed.
  • The practice had a number of policies and procedures to govern activity, although a few contained out of date or missing information.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events, and learning from significant events and complaints was shared to support improvement.
  • The practice had identified the needs of its population and was working closely with a community link worker to support the population.
  • Staff felt supported by management; however the leadership structure was not clear.
  • The practice proactively sought feedback from staff and patients, which it acted on.

However, there were also areas of practice where the provider needs to make improvements.

The provider must:

  • Ensure that recruitment checks, including indemnity insurance and Disclosure and Barring, are completed for all staff including locums prior to starting work in the practice.
  • Ensure that training records are maintained for all staff, including locums, to ensure that they have the skills, knowledge and experience to deliver effective care and treatment.
  • Ensure that a clear leadership structure is in place with roles and responsibilities clearly defined.
  • Ensure that computer printable prescription paper is stored securely.
  • Ensure that systems for safety checking within the practice are completed and monitored, including medicine and consumable expiry dates and infection control.

The provider should:

  • Review the emergency medicines held on site.
  • Continue to review and update practice policies.
  • Review and improve uptake of health screening by patients within the practice.

Although I recognise improvement made to the quality of care provided by the service, the practice had failed to make sufficient improvement in some areas. I am therefore extending the period of special measures for a further six months.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shada Parveen (The Maybury Surgery) on 15 November 2016. The overall rating for the practice was inadequate. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Shada Parveen on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 27 April 2017 to confirm that the practice was compliant with warning notices issued following the November 2016 inspection. The warning notices were issued against regulation 12 (1) (safe care and treatment), regulation 17 (1) (good governance) and regulation 19 (1) and (2), 19 (3) and (4) (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This report covers our findings in relation to those requirements. The ratings remain unchanged from the November 2016 inspection as the purpose of the April 2017 inspection was to review compliance against the warning notices issued.

Our key findings were as follows:

  • The practice had made improvements to recruitment processes and we saw that appropriate employment checks had been carried out on staff including references, identification checks and Disclosure and Barring Service (DBS) checks.

  • There was evidence of improvements made to incident reporting, discussion and learning.

  • Clinical equipment had been tested to ensure it was working properly.

  • The practice had developed a system to ensure that vaccines were in date and fit for use, they had carried out a clinical audit of vaccines used across a six month period to ensure that no out of date vaccines had been administered.

  • Printer prescriptions were now locked away when not in use and there was a prescription tracking system in use in the practice.

  • The practice was developing a programme of clinical audit and had identified ways to improve patient outcomes in relation to the management of long term conditions, specifically in relation to diabetes care.

  • The practice had taken action to improve infection control practices including identifying clear leadership and carrying out an infection control audit. However, not all staff had received infection control training and two of three sharps bins in the practice had not been labelled appropriately.

  • The practice had taken action to improve communication, including holding regular staff meetings.

  • The practice had re-engaged with the patient participation group (PPG) and had held one meeting with another one planned.

    However, there were also areas of practice where the provider needs to make improvements.

  • There continued to be some gaps in risk management with areas of potential risk not adequately mitigated through the use of risk assessments including control of substances hazardous to health (COSHH) and the security of the premises. Fire safety and defibrillator risk assessments had been carried out, however these did not always identify the specific risks or adequately mitigate them.

  • There was a system in place to review and update practice policies, however the information contained in the reviewed policies was seen to be out of date in some cases and not all staff had signed to say they had read and understood them.

Importantly, the provider must:

  • Ensure that all environmental risks are identified through a process of risk assessments where all risks are clearly and adequately mitigated.

  • Ensure that policies are comprehensively reviewed and that information contained in them is current and relevant and that all staff have read and understood them.

In addition the provider should:

  • Ensure that sharps bins are appropriately labelled.

  • Ensure that all staff attend infection control training that is relevant to their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Maybury Surgery (Dr Shada Parveen) on 15 November 2016. Overall the practice is rated as inadequate.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and infection control audits and activities were inconsistent.
  • While there was evidence of some incident reporting, the recording, investigation, discussion and learning as a result was insufficient.
  • Records relating to complaints were limited and it was unclear how complaints were reviewed, discussed and learning used to make improvements.
  • Risk assessment and management processes were not embedded in the practice. For example there was no health and safety, security, fire safety, legionella or control of substances hazardous to health (COSHH) risk assessments in place within the practice. However, we were told that a legionella risk assessment was kept by the owner of the building. Risks had not been mitigated, for example staff had not attended fire training, there had been no routine test of the fire alarm system and no evacuation drill.
  • Clinical equipment had not been tested to ensure it was working properly.
  • There were out of date vaccines in the vaccination fridge and records of regular medicine and emergency equipment checks were not available.
  • Printer prescriptions were not locked away when not in use and there was no tracking of prescriptions within the practice.
  • The practice had not assessed the risk of not having a defibrillator on site.
  • There were no completed full cycle audits and it was unclear how audits were being used to improve patient outcomes.
  • Induction plans for new staff did not cover areas of mandatory training and there was evidence of gaps in training for staff. Training records were often out of date or not in place so the practice could not demonstrate who had up to date training in place.
  • Staff had not received appraisals in the last 12 months and not all staff had received training relevant to their role.
  • There was inconsistent care planning and no record of multi-disciplinary meetings.
  • The practice had an inconsistent approach to offering chaperones and the option of having a chaperone was not advertised within the practice.
  • The uptake of health screening by the patient population was low and it was unclear how the practice was addressing this.
  • The practice had limited formal governance arrangements and leadership was unclear in some areas.
  • The content of practice policies had not been regularly reviewed with staff identified as having responsibilities in some areas no longer working for the practice.
  • The practice did not have an active Pateint Participation Group and the use of proactive patient feedback approaches was limited although there was some evidence of the practice responding to feedback in relation to reinstating their walk in service.
  • The practice had a flexible approach to providing appointments and patient feedback about access to the service was positive.
  • We observed staff to be kind and caring and saw that patient’s dignity was respected.
  • Staff had a good understanding of how to support patients who were vulnerable and we observed the practice manager supporting one patient to make calls to address social care issues.
  • Results from the GP patient survey showed the practice was below average in relation to the number of patients who would recommend the practice and in relation to GP consultations. However, recent results from the friends and family test showed that 100% of those responding would recommend the practice to their friends and family.
  • The practice had a comprehensive business continuity plan in place and this had been effectively utilised during a recent incident that impacted the service.
  • 90% of newly diagnosed patients with diabetes had been referred to a structured education programme within nine months of entry onto the register. This was 26% higher than the CCG average and 19% higher than the national average.

The areas where the provider must make improvements are:

  • Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents, near misses and complaints.
  • Take action to address identified concerns with infection prevention and control practice.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure there is a consistent and safe approach to the use of chaperones within the practice.
  • Ensure that care plans are in place and that evidence of multi-disciplinary discussions and reviews are appropriately recorded.
  • Carry out clinical audits including re-audits to ensure improvements have been achieved.
  • Implement formal governance arrangements including systems for assessing, monitoring and managing risks and the quality of the service provision.
  • Ensure that medicines management processes are in place for the effective storage, monitoring and review of all medicines management systems including vaccines and the security of prescriptions.
  • Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
  • Ensure staff receive regular appraisals and training relevant to their role.
  • Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
  • Ensure that there is an active Patient Participation Group put in place with effective feedback processes and evidence of on-going action to address issues identified.

In addition, areas where the provider should make improvements are;

  • Take action to improve the uptake of health screening by the patient population.
  • Continue to improve patients overall experience relating to whether or not patients would recommend the practice and GP consultations.
  • Review exception reporting within the practice and identify areas where this could be brought in line with CCG averages.
  • Review childhood immunisation rates to ensure these are in line with CCG averages.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 August 2014

During a routine inspection

This was a follow up inspection to check the provider had taken the required actions to meet essential standards following our previous inspection in February 2014. We had previously found the provider non-compliant in patient care and welfare and supporting staff. We found at this inspection the provider had taken all necessary action and was now compliant with the regulations.

At the last inspection patients told us that getting an appointment could be difficult due to the practices opening times. We saw that the practice had changed their appointment system and two days a week there was a walk in service with no appointment necessary. The practice had also extended its opening time two days a week.

Staff had received basic life support training which included Cardio Pulmonary Resuscitation (CPR) and had knowledge of the emergency / contingency plans for the practice in case of an emergency.

The practice was actively recruiting for new staff. The practice manager was able to explain the induction process and subsequent appraisals and mandatory training needed for new starters. We spoke with a reception / administration staff member who had been at the practice three months. They told us they felt supported by the practice and staff. We were able to see evidence of staff appraisals and a planned appraisal for August 2014.

We spoke with two patients who told us the practice was helpful and caring and they had no problems getting appointments when needed. They thought the walk in sessions were very useful.

17, 18 February 2014

During a routine inspection

We carried out this inspection over two mornings to look at the care and welfare provided by Dr Shada Parveen's Surgery. During our visits we spoke with two patients and three reception staff. We spoke briefly with the GP before surgery began. We spoke to the community midwife who was visiting that day. We also collected six responses to a questionnaire we left in the waiting area. We tried to contact the practice nurse and the GP for further information following our inspection, but were unable to get a response.

On the first day of our inspection we were told that the practice had been going through significant change at partner level. We spoke to staff who told us that due to the changes at the practice they had not received regular training or appraisals.

We heard that patients were asked for, and gave their consent before any treatment or examination took place and their wishes were respected by staff. One patient told us 'They would listen and respect my wishes if I said no.'

Patients told us that they were satisfied with their care. We saw that the practice had an emergency plan to implement in case of significant events, but staff were unaware of this.

Staff were aware of safeguarding vulnerable adults and children. When asked, patients told us that they felt safe at this surgery.

We saw that the practice had a complaints policy and that this was under review. However, all but one patient told us they would not know how to make a complaint.