Archived: Dr Ahsanulhaq Goni Also known as Shakespeare Road PMS

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Ahsanulhaq Goni on 25 October 2016. Overall the practice is rated as requires improvement.

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

• There was a system in place for reporting and recording significant events although this was not applied consistently.
• There were some systems in place to manage risks to patients. However, systems relating to infection prevention and control, monitoring the health and safety at the branch site and management of blank prescriptions must be improved.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvement are:

• The system for reporting and recording significant events must be improved and applied consistently with learning shared across staff groups.
• An effective system to monitor infection prevention and control in the practice must be implemented and an action plan developed to show how and when improvements are to be made to address shortfalls. Action must be taken to address grouting missing from tiles around the sink and gap and marks/stains in the flooring in the health care assistant’s room at Shakespeare Road Surgery.
• Arrangements for the storage and transportation of blank prescription forms must be risk assessed and procedures brought into line with NHS Protect: Security of prescription forms guidance.
• The practice must ensure when employing new staff that two written references are obtained prior to employment.
• The practice must obtain copies of health and safety risk assessments undertaken by the landlord for the branch site to ensure all actions that are the responsibility of the provider are completed. The provider must periodically check health and safety records at the branch site in order to assure themselves all actions were being undertaken by the landlord. The provider must ensure weekly fire alarm tests are carried out at the branch site and establish what action has been taken in respect of the emergency lights at the branch site which had failed a test on 18 October 2016.
• The provider must provide a warning sign where oxygen is stored.
• The provider must implement the Department of Health guidance February 2015 relating to blinds and blind cords to minimise the risk of serious injury due to entanglement.

The areas where the provider should make improvement are:

• The chaperone policy and procedure should be reviewed and updated to reflect the staff responsibilities for recording when chaperones are provided.
• The provider should take account of the Department of Health guidance: HBN 00-09 - Infection control in the built environment, in relation to flooring in treatment areas and hand washing facilities and develop and implement an action plan to improve these areas.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice