Archived: Umar Medical Centre Also known as Dr A Alam & Dr S Adam

We carried out an announced comprehensive inspection at Umar Medical Centre on 7 March 2018. The overall rating for the practice was inadequate and we issued warning notices for breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and Treatment) and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). The full comprehensive report following the inspection in March 2018 can be found on our website here: https://www.cqc.org.uk/location/1-583513367/reports.

This inspection was an unannounced focused inspection carried out on 31 July 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches identified within the warning notices.

At this inspection we found:

• The practice had made improvements to systems and processes to ensure that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• A new protocol had been implemented to ensure incoming correspondence to the practice was managed effectively and in a timely manner. Staff we spoke with were aware of this protocol and their responsibilities relating to it and we saw evidence the provider had carried out an audit to ensure the new process was working as intended.
• While risk assessments had been completed around fire and legionella, mitigating actions identified as a result had not been undertaken. The same was found in relation to the infection prevention and control audit recently completed.
• While recruitment checks relating to locum GPs employed by the practice had improved, we found gaps in the pre-employment checks completed for three new permanent members of staff.
• The practice had made improvements around oversight of staff training and development needs and had produced an appraisal schedule to ensure staff received an appropriate appraisal in a timely manner.

At our previous inspection on 7 March 2018, we rated the practice as inadequate and placed the service into special measures. As per our published inspection methodology, a further full comprehensive inspection visit will be carried out within three months to monitor the work the practice has started to produce the required improvements to the service.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

This practice is rated as Inadequate overall. (Previous inspection July 2016 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

We carried out an announced comprehensive inspection at Umar Medical Centre on 7 March 2018 in response to concerns raised by members of the public.

At this inspection we found:

• The practice was negotiating a period of transition with recent changes to the GP partnership and a newly appointed practice manager. The practice had also experienced a turbulent time over recent months with staff absence.

• There was some confusion amongst staff around roles, responsibilities and the staffing structure. We found staff morale was low with limited evidence of a team ethos.

• The practice lacked clear systems to manage risk and mitigate against the repeat of safety incidents. When incidents did happen, we found examples where the practice had not learned from them or improved its processes.

• There was limited evidence of clinical audit or quality improvement to demonstrate the effectiveness and appropriateness of the care provided.

• Staff delivered care and treatment according to evidence-based guidelines.

• The practice demonstrated an awareness of the patient population it served and took pride in being integrated into the local community. The GPs delivered healthcare awareness sessions at the local mosque and schools.

• We found significant gaps in governance arrangements. There were gaps in practice policies and procedures to govern key activities.

• The practice was unable to evidence that an infection prevention and control audit had been completed.

• There was a lack of managerial oversight of training and staff training needs. Appraisals for staff had not been completed regularly.

• Information flow within the practice was largely informal. The practice lacked a meeting structure to formally document the dissemination of any changes to staff.

• Patients rated the practice lower than others for many aspects of care, although patients told us staff involved and treated them with compassion, kindness, dignity and respect.

• Patients found the appointment system confusing to use and reported that they could not always access care when they needed it.

• The practice lacked a systematic approach to managing and responding to patient complaints.

• There was confusion and dysfunction in how the practice managed incoming post.

The areas where the provider must make improvements as they are in breach of regulations are:

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

• Ensure there is an effective system for identifying , receiving ,recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

• 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:

• Work should continue to identify and support patients who are also carers.

• Undertake activity to proactively promote uptake of breast and bowel cancer screening.

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