Dr Samir Naseef Also known as Orient House Medical Centre

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection as part of our inspection programme at the practice of Dr Samir Naseef on 26 August 2016 which was rated as requires improvement overall. The key questions were rated as:

Safe – requires improvement

Effective – requires improvement

Caring – good

Responsive – requires improvement

Well led – requires improvement

We carried out a focused follow up inspection on 1 June 2017 where we found the practice had made significant improvements in the key questions responsive and well led which were rated as good. The practice was rated requires improvement overall as improvements still needed to be made in the key questions safe and effective. The full comprehensive and follow up reports for these inspections can be found by selecting the ‘all reports’ link for Dr Samir Naseef on our website at www.cqc.org.uk.

At this inspection the areas that required improvement were:

• The provider had failed to identify the risks associated with the type of blinds fitted throughout the surgery which were not compliant with current and safe standards.
• The provider had failed to ensure that persons employed received such support, training, professional development, supervision and appraisal as was necessary to enable them to carry the duties they were employed to perform. They did not have a robust induction process that prepared staff for their role.
• The provider did not hold information such as ID, references, DBS checks in the files of all its employees.
• The provider had not completed the required actions identified in a legionella risk assessment.

This inspection was an announced focused inspection carried out on 17 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 1 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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Overall the practice is now rated as good. Since the last inspection the provider had recruited a new practice manager who had made the following improvements

• The provider had ensured that all blinds in the surgery were cleated and were now compliant with current and safe standards.
• The provider had completed the required actions identified in a legionella risk assessment
• The provider had introduced a training programme and an induction process that prepared staff for their role and offered support and supervision.
• The practice manager had ensured a plan for the appraisal process was in place and to carry out appraisals for all staff in the coming weeks.
• The provider had introduced a policy where information, such as ID, references and DBS checks would be held for new staff and, where appropriate existing staff.

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

Importantly, the provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Dr Samir Naseef on 1 June 2017. Overall the practice is still rated as requires improvement.

The practice had been previously inspected on 26 August 2016. Following that inspection the practice was rated as overall requires improvement with the following domain ratings:

Safe – Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive – Requires improvement

Well led - Requires Improvement

At that time:

• The registered person did not do all that was reasonably practicable to assess, monitor, manage and mitigate risks to the health and safety of service users.
• The provider did not have a robust induction process that prepared staff for their role.
• The provider did not hold information such as ID, references, DBS checks in the files of its employees.

The practice provided us with an action plan detailing how they were going to make the required improvements.

The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr Samir Naseef on our website at www.cqc.org.uk.

This full comprehensive inspection on 1 June 2017 was to confirm if the required actions had been completed and award a new rating if appropriate. Following this re-inspection, our key findings across all the areas we inspected were as follows:

Since the last inspection the practice had made the following improvements:

• The practice had carried out risk assessments in relation to the building such as fire safety, gas safety, substances hazardous to health and legionella, although required actions identified in the legionella assessment had yet to be completed.
• The practice had carried out one clinical audit and had a plan in place when other audits would be carried out, including second cycles.
• Practice policies and procedures were now in place and staff knew where to find them.
• The practice now had a system for reporting, recording, acting on and monitoring of significant events.
• The practice now had a process for receiving, recording and acting on complaints received.

Other key findings were as follows:

• Blinds at all windows in the surgery did not meet safety requirements and were potentially hazardous due to them having a loop system in place.
• The inspection team did not have access to staff files during the inspection and were unable to see evidence that effective recruitment procedures had been put in place since the last inspection. Information provided after the inspection did not include full and necessary employment checks for new members of staff.
• The practice did not provide evidence that they had introduced a robust induction programme which would prepare new staff for their role.
• The practice had a systematic process of dealing with and monitoring updates and guidelines from the National Institute for Health and Care Excellence.(NICE)
• Feedback from patient surveys and Family and Friends test were consistently positive about the practice. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Some staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Staff felt supported by the lead GP. The practice proactively sought feedback from staff and patients, which it acted on.
• The practice had recruited a new practice manager who was due to start with the practice the day after the inspection. The practice told us that the previous manager had left in March 2017.
• The provider was aware of and complied with the requirements of the duty of candour.

However there are areas where the provider still must make improvements :

• Ensure premises being used to care for and treat service users are safe to patients
• Ensure persons employed in the provision of regulated activities receive the appropriate training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

In addition the provider should:

• Complete the required actions identified in the legionella risk assessment.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice