Dr Mohammed Fateh

We carried out an announced inspection at Dr Mohammed Fateh on 09 June 2022. Overall, the practice is rated as Requires improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led - Requires improvement

Following our previous inspection on 13 October 2016, the practice was rated Good overall and for all key questions. We found no breaches of regulations.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Mohammed Fateh on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on concerns identified during a TMA call with the provider on 30 November 2020 and a subsequent DMA call on 06 April 2022 and covers our findings in relation to the actions we told the practice they should take to improve. We also inspected the branch site at Rainham Surgery. The Branch site shares the same patient list as the main site.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A 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 have rated this practice as Requires Improvement overall.

We found that:

• There were some areas of risk that were not effectively managed, related to risks in the main surgery building, particularly from fire safety.
• The provider did not have effective systems in place to review monitoring appropriately. We were not assured that patients were always receiving the correct care, treatment and monitoring for their conditions.
• Some performance data was below local and national averages. The practice had not met targets for cervical screening and childhood immunisations. However, there were robust recall systems and performance against these targets was continually reviewed and monitored.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• We found evidence of quality improvement measures including clinical audits and reviews. There was evidence of action taken to change practice.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. However, the governance arrangements in place were not effective, especially in relation to identifying, managing and mitigating risks.
• There were arrangements to ensure that data or notifications are submitted to external bodies including CQC, as required.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found breaches of regulations. The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report). Requirement notices were issued for the additional concerns which related to breaches identified. The level of risk stemming from these concerns was not deemed to be sufficient to require additional enforcement action.

The areas the provider should make improvements are:

• Continue to improve uptake for screening and immunisation programmes.
• Improve compliance with policies and procedures; for example, the fire safety policy.
• Review arrangements for meeting with the patient participation group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services