1 June 2023
During an inspection looking at part of the service
We carried out an announced focused inspection at Dr Isam Saleh on 1 June 2023. Overall, the practice is rated as inadequate.
Safe - Inadequate.
Effective – Inadequate.
Caring – Rating of good, carried forward from previous inspection.
Responsive – Requires improvement.
Well-led – Inadequate.
Following our previous inspection on 7 December 2016, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Isam Saleh on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up concerns reported to us in response to risk in line with our inspection priorities. During the inspection we reviewed 4 of our 5 key questions, safe, effective, responsive and well-led.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
Our findings
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 found that:
- The practice did not provide care in a way that kept patients safe and protected them from avoidable harm.
- The practice did not have an effective system to ensure patients on medicines that required monitoring were appropriately managed in a timely way.
- The practice was not effectively assessing the risk of preventing and controlling the spread of infections.
- Medicines and equipment were not being managed in a safe and effective manner.
- Prescriptions were not kept securely, and their use was not monitored in line with national guidance.
- Safeguarding processes were not safe or effective.
- Patient records of care and treatment were not managed in a safe and effective way.
- Patients did not always receive effective care and treatment that met their needs. Their needs were not assessed and care and treatment was not always delivered in line with current legislation, standards and guidance.
- The system for monitoring patients with long-term conditions was ineffective.
- There were not effective processes in place to ensure that persons had access to and received cervical cancer screening.
- The practice facilities were not being managed appropriately for the services being delivered.
- Learning from complaints was not used to improve the quality of care.
- The way the practice was led and managed did not promote the delivery of high-quality, person-centred care.
- There were ineffective systems in place for the management of significant events.
- There was not an effective system to ensure that staff working in the practice completed the required training as directed by the practice policies.
- The overall governance arrangements were ineffective.
- The practice did not have clear and effective processes for managing risks, issues and performance.
We found multiple breaches of regulations.
- Care and treatment was not provided in a safe way to patients.
- Patients were not protected from abuse and improper treatment.
- Premises and equipment used by the service provider was not fit for use.
- Effective systems and processes to ensure good governance in accordance with the fundamental standards of care were not established.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Following the inspection we took action to cancel the provider’s registration. This service is now closed.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care