Archived: Khattak Memorial Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Khattak Memorial Surgery on 17 January 2017. Overall the practice was rated as requires improvement. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Khattack Memorial Surgery on our website at www.cqc.org.uk.

This inspection was a follow up focused inspection carried out on 22 August 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 17 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice rating is now good.

Our key findings were as follows:

• Staff were aware of the location of emergency equipment to assure themselves that they all knew how to assist in the event of an emergency. We were shown evidence that demonstrated this had been discussed in staff meetings and staff had been physically shown the location.

• The practice had reviewed the information governance policy to ensure that staff undertook the recording and management of all patient data in accordance with recommended guidance.

• The practice had introduced an appropriate method of recording fridge temperatures, cleaning activity and safeguards against the risk of legionella to ensure that the practice was accountable and auditable.

• Cleaning checks were recorded daily.

• The practice continued to address issues raised in the national patient survey and explore ways to gather up to date patient feedback to assure themselves that improvements were implemented, reviewed and sustained. For example, from September 2017, the practice’s telephone lines would be open 30 minutes earlier.

• Registration details have been updated with the Care Quality Commission to include all current GP partners in the practice.

• Regular fire drills had been implemented at the branch site.

• The practice had improved the availability of copies of the business continuity plan at both sites managed by the provider to cover eventualities such as power failure or another unforeseen eventuality. Copies were kept within the practice and off-site by GP partners and the practice manager.

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 Khattak Memorial Surgery on 17 January 2017. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed. However, the process of monitoring temperature sensitive medicines, staff awareness of emergency medicines and information governance within the practice required improvement.
• The practice had good facilities, which could be adapted to support patients with mobility needs and was well equipped to treat patients.
• There was continuity of care, with urgent and telephone appointments available the same day and walk in appointments were available for children under the age of 5, patients living withcancer or a terminal illness, and patients over the age of 75.
• 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.
• The practice had effective administrative and communication systems to ensure results and correspondence from secondary care was dealt with promptly.
• There was a clear and visible leadership structure and staff felt supported by management.

• The provider had a domiciliary nurse who visited the frail and housebound offering a wide range of nursing care within the community. Care was extended to social prescribing and support for vulnerable patients, especially those experiencing mental health difficulties.

• The provider shared with the families of patients whose death was expected the personal contact details of their GP, so that support and death certification could be received day or night in accordance with cultural preferences.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from the patient participation group.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure that all staff are aware of the location of emergency equipment to assure themselves that all staff will know how to assist in the event of an emergency.

• Review the information governance policy to ensure that staff undertake the recording and management of all patient data in accordance with recommended guidance.

• Improve the methods of recording fridge temperatures, cleaning activity and safeguards against the risk of legionella to ensure that the practice is accountable and auditable.

In addition the provider should:

• Continue to address issues raised in the national patient survey and explore ways to gather up to date patient feedback to assure themselves that improvements are implemented, reviewed and sustained.

• Update registration details with the Care Quality Commission to include all current GP partners in the practice as soon as possible.

• Take steps to complete regular fire drills at the branch site.

• Improve the availability of copies of the business continuity plan at both sites managed by the provider to cover eventualities such as power failure or other unforeseen eventuality.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice