dr arshad khan newapproachcomprehensive report ... ·...

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Good –––

DrDr ArArshadshad KhanKhanQuality Report

Central Medical Centre, 42 St Paul’s RdCoventry, CV6 5DFTel: 024 7668 1231Website:

Date of inspection visit: 15 January 2015Date of publication: This is auto-populated when thereport is published

1 Dr Arshad Khan Quality Report This is auto-populated when the report is published

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 3

The six population groups and what we found 5

What people who use the service say 7

Areas for improvement 7

Detailed findings from this inspectionOur inspection team 8

Background to Dr Arshad Khan 8

Why we carried out this inspection 9

How we carried out this inspection 9

Detailed findings 0

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out a comprehensive inspection of Dr ArshadKhan (Central Medical Centre) on 15 January 2015.Specifically, we found the practice to be good forproviding safe, effective, caring, responsive and well-ledservices. It was also good for providing services for theolder people, people with long-term conditions, families,children and young people, working age people(including those recently retired and students), peopleliving in vulnerable circumstances, and peopleexperiencing poor mental health (including people withdementia).

Our key findings were as follows:

• The practice had comprehensive systems formonitoring and maintaining the safety of the practiceand the care and treatment they provided to theirpatients

• The practice was proactive in helping people with longterm conditions to manage their health and hadarrangements in place to make sure their health wasmonitored regularly

• The practice was clean and hygienic and had robustarrangements for reducing the risks from healthcareassociated infections

• Patients felt that they were treated with dignity andrespect. They felt that their GP listened to them andrespected them

• The practice had a well-established and well trainedteam with expertise and experience in a wide range ofhealth conditions

There were areas of practice where the provider needs tomake improvements.

The provider should:

• Ensure minutes of meetings consistently recorddecisions taken and identify staff responsible forcompleting actions.

• The practice should ensure evidence of identity is heldfor all staff employed.

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

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as good for providing safe services. Staffunderstood and fulfilled their responsibilities to raise concerns andreport incidents and near misses. The practice providedopportunities for the staff team to learn from significant events andwas committed to providing a safe service. Information about safetywas recorded, monitored, appropriately reviewed and any safetyissues addressed. The practice assessed risks to patients andmanaged these well. There were enough staff to keep people safe.

Good –––

Are services effective?The practice is rated as good for providing effective services. Datashowed patient outcomes were at or above average for the locality.Over the last two years, the practice has improved its performancewhen compared with others within the Coventry and Rugby ClinicalCommissioning Group (CCG). Patients’ care and treatment tookaccount of guidelines issued by the National Institute for Care andHealth Excellence (NICE). Patients’ needs were assessed and carewas planned and delivered in line with current legislation. Thepractice was proactive in the care and treatment provided forpatients with long term conditions and regularly audited areas ofclinical practice. There was evidence that the practice worked inpartnership with other health professionals and was a member ofthe local Godiva Prescribing Quality Programme. As a result thepractice had been able to reduce prescribing of certain medicines inline with medical guidelines more effectively. Staff received trainingappropriate to their roles and the practice supported andencouraged their continued learning and development.

Good –––

Are services caring?The practice is rated as good for providing caring services. Patientstold us they were treated with compassion, dignity and respect andthey were involved in care and treatment decisions. Accessibleinformation was provided to help patients understand the careavailable to them. We saw that staff treated patients with kindnessand respect and were aware of the importance of confidentiality.The practice provided advice, support and information to patients,particularly those with long term conditions, and to familiesfollowing bereavement.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Thepractice was aware of the needs of their local population andengaged with the NHS Area Team and Clinical Commissioning Group

Good –––

Summary of findings


(CCG) to secure service improvements where these were identified.Although previous survey results indicated below averageperformance in terms of patient experience and access, we saw thatthe practice had taken action to address these areas. Patients wespoke with during our inspection reported good access to thepractice and said that urgent appointments were available on thesame day. The practice had good facilities and was well equipped totreat patients and meet their needs. There was a clear complaintssystem with evidence demonstrating that the practice respondedquickly to issues raised. The practice had a positive approach tousing complaints and concerns to improve the quality of the service.

Are services well-led?The practice is rated as good for being well-led. It had a clear visionand strategy. Staff were clear about the vision and theirresponsibilities in relation to this. There was a clear leadershipstructure and staff felt supported by management. The practice hada number of policies and procedures to govern activity and heldregular governance meetings. There were systems in place tomonitor and improve quality and identify risk. The practiceproactively sought feedback from staff and patients, which it actedon. The patient participation group (PPG) was active. Staff hadreceived inductions, regular performance reviews and attended staffmeetings and events.

Good –––

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThis practice is rated as good for the care of older patients. Patientsover the age of 75 had a named GP and where appropriate, wereincluded on the practice’s avoiding unplanned hospital admissionslist to alert the team to patients who may be more vulnerable. TheGPs carried out visits to patients’ homes if they were unable to travelto the practice for appointments. At the time of our inspection, thepractice had just completed delivering its flu vaccinationprogramme. The practice nurse had arranged to do these atpatients’ homes if their health prevented them from attending theclinics at the surgery.

Good –––

People with long term conditionsThis practice is rated as good for the care of patients with long termconditions, for example asthma, diabetes and Chronic ObstructivePulmonary Disease (COPD), a lung condition. The practice hadeffective arrangements for making sure that patients with long termconditions were invited to the practice for annual reviews of theirhealth. Members of the GP and nursing team at the practice ranthese clinics. Patients whose health prevented them from being ableto attend the surgery received the same service from one of thepractice nurses as home visits were arranged. The practice had ahigh percentage of patients (10%) with diabetes. As a result, thepractice employed a specialist diabetes nurse, who was also aprescriber for one day every week. In 2014, a pilot scheme wasorganised which saw diabetic patients have clinics at the practicewith a diabetic consultant from George Eliot Hospital, Nuneaton toidentify and improve outcomes for patients.The practice hasdeveloped a partnership with an independent health provider toand review patients with? asthma and Chronic ObstructivePulmonary Disease (COPD), a lung condition.

Good –––

Families, children and young peopleThis practice is rated as good for the care of families, children andyoung people. The practice held weekly childhood vaccinationclinics. There was a weekly antenatal clinic. At the time of our visit,the practice did not run a dedicated baby clinic, but we were shownplans to launch one during spring 2015. GPs told us however, howbabies and children were given priority in the appointment systemand this was supported by comments made by patients. Child flu

Good –––

Summary of findings


vaccinations were also provided. A midwife came to the practicetwice weekly to see expectant mothers. Appointments wereavailable outside of school hours and the premises were suitable forchildren and babies. The practice offered a family planning service.

Working age people (including those recently retired andstudents)This practice is rated as good for the care of working age patients,recently retired people and students. The practice providedextended opening hours until 6.30pm four days each week forpatients unable to visit the practice during the day. The practice alsohad arrangements for patients to have telephone consultations witha GP. The practice was proactive in working to offer online servicesand at the time of our visit was developing a new website tofacilitate this. Health promotion included smoking cessation andhealthy eating advice.

Good –––

People whose circumstances may make them vulnerableThis practice is rated as good for the care of patients living invulnerable circumstances. The practice monitors patients withlearning disabilities (LD). All patients with learning disabilities wereinvited to attend for an annual health check. The practice regularlyworked with multi-disciplinary teams with vulnerable patients. Staffknew how to recognise signs of abuse in vulnerable adults andchildren. Staff were aware of their responsibilities regardinginformation sharing, documentation of safeguarding concerns andhow to contact relevant agencies in normal working hours and outof hours.

Good –––

People experiencing poor mental health (including peoplewith dementia)This practice is rated as good for the care of patients experiencingpoor mental health (including people with dementia). The practicehad a register of patients at the practice with mental health supportand care needs and invited them for annual health checks. Thepractice works in partnership with the local Community MentalHealth Team to identify patients’ needs and to provide patients withcounselling, support and information. Patients were referred to amemory clinic when this was felt to be appropriate.

Good –––

Summary of findings


What people who use the service sayResults from the GP national patient survey were belowaverage nationally and for the Coventry and RugbyClinical Commissioning Group (CCG). A total of 43.3% ofpatients surveyed found it easy to get through to thepractice on the telephone, 46% of patients wouldrecommend the practice to friends and family and 53% ofpatients said the last time they saw a GP, they felt theyhad been given enough time.

However, most patients we spoke with told us theavailability of appointments was good, although onepatient told us it was difficult to get through on thetelephone at times. GPs and patients told us that if anappointment was needed in an emergency and all theappointment slots were full, additional appointmentswere made on the same day to ensure all patients whorequired an urgent appointment were seen.

We gathered the views of patients from the practice bylooking at 30 CQC comment cards patients had

completed and by speaking in person with ten patients.Some patients who gave us their views had been patientsat the practice for many years. Patients were largelypositive above the practice and commented on howprofessional, friendly and helpful staff and GPs were.

After our inspection, we spoke by telephone with apatient who was involved with the Patient ParticipationGroup (PPG). The purpose of the PPG was to act as anadvocate on behalf of patients when they wished to raiseissues and to comment on the overall quality of theservice. This ensured patient views were included in thedesign and delivery of the service.

Patients told us they were treated with dignity andrespect and the GPs, nurses and other staff providedgood care. Patients we spoke with expressedappreciation for the service they had received and somehad recommended the practice to friends and familymembers.

Areas for improvementAction the service SHOULD take to improve

• The practice should ensure minutes of meetingsconsistently reflect who attended meetings, decisionstaken and identify staff responsible for completingactions.

• The practice should ensure evidence of identity is heldfor all staff employed.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC inspector. Theinspection team also included a GP specialist advisorand an expert by experience (a person who hasexperience of using this particular type of service, orcaring for somebody who has).

Background to Dr ArshadKhanDr Arshad Khan (Central Medical Centre) is situatedapproximately a mile to the north of Coventry city centre.The practice has been in existence for over thirty years. Ithas 3,520 patients.

The practice is in an area with a high ethnic population and70% of patients do not speak English as their first language.Patients’ health needs reflect the ethnic community. Thereis a high rate of diabetes, over twice the national average(10% of patients) and a high rate of coronary heart disease.The practice has a higher than average proportion ofpatients with long term medical conditions and who aresmokers. The practice is located within a designateddeprived area and income deprived families are more thandouble the national average. There is a high rate ofunemployment. The practice has one of the most deprivedpatient lists within the Coventry and Rugby ClinicalCommissioning Group (CCG). The level of deprivation is30% above the CCG average.

The practice provides a range of NHS services including anantenatal clinic, family planning service and smokingcessation support. The practice also undertakes minorsurgical procedures. The community midwife visits thepractice twice weekly.

The practice has one male GP, a locum female GP(employed by the practice), a practice nurse and anassistant practice nurse. Chaperones are used for patientswho request the service, which is advertised throughoutthe practice. Working alongside the clinical team is apractice manager, and administrative and reception staff.

The practice has a Primary Medical Services (PMS) contractwith NHS England. A PMS contract is a contract betweengeneral practices and NHS England for delivering primarycare services to local communities.

This was the first time the Care Quality Commission (CQC)had inspected the practice. Based on information wegathered before the inspection we had no specificconcerns about the practice. Data we reviewed showedthat the practice was achieving results that were average orslightly below average in some areas with the England orClinical Commissioning Group. Results from the GPnational patient survey were below average nationally andfor the Coventry and Rugby Clinical Commissioning Group(CCG), for example 46.1% of patients would recommendthe practice to friends and family.

The practice does not provide out of hours services to theirown patients. Patients are provided with information aboutlocal out of hours services which they can access by usingthe NHS 111 phone number.

DrDr ArArshadshad KhanKhanDetailed findings


Why we carried out thisinspectionWe inspected this service as part of our comprehensiveinspection programme.

We carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. This inspection wasplanned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

How we carried out thisinspectionBefore this inspection, we reviewed a range of informationwe hold about the practice and asked other organisationsto share what they knew. These organisations includedCoventry and Rugby Clinical Commissioning Group (CCG),

NHS England area team and Healthwatch. We carried outan announced visit on 15 January 2015. During theinspection we spoke with a range of staff (GPs, nurses,practice manager, reception and administrative staff). Wespoke with ten patients who used the service, andcontacted a further patient, a member of the PatientParticipation Group (PPG) after our visit.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services are provided forspecific groups of people and what good care looks like forthem. The population groups are:

• Older people• People with long-term conditions• Families, children and young people• Working age people (including those recently retired

and students)• People living in vulnerable circumstances• People experiencing poor mental health (including

people with dementia)

Detailed findings


Our findingsSafe track recordDuring our inspection of Dr Arshad Khan, we reviewed howthe practice identified risks and carried out actions toimprove patient safety. We reviewed documentation for thelast two years, this included six safety incidents.Documents included safety records, reports of incidentsand the minutes of meetings when such matters had beendiscussed within the practice.

The practice used various methods to enable staff toidentify risks and take appropriate action to improvepatient safety when needed. This included processes forreporting incidents and disseminating informationcontained within national patient safety alerts to allrelevant staff. It was evident the practice also assessedinformation gathered from clinical audits and health andsafety audits it had carried out, with patient safety as apriority.

The practice also reviewed safety following comments andcomplaints they received from patients and staff. Forexample, we were shown how the practice improvedprocedures for document control and storage after apatient’s record was lost.

Records we examined demonstrated the practice hadeffectively managed safety incidents and had evidence of asafe track record over a longer timescale.

Learning and improvement from safety incidentsAppropriate systems had been implemented by thepractice to report, record and monitor all significant events.This included incidents and accidents. We looked at anysignificant events that had occurred within the last twoyears. We found incident records had been correctlycompleted within an appropriate time and when patientshad been affected by a necessary change or somethingthat had gone wrong, in line with practice policy, they weregiven an explanation and if necessary, an apology andinformed of the actions taken.

We reviewed one incident when an incorrect medicationhad been issued to a patient. The practice quicklycorrected the error and ensured there had been no healthrisks to the patient. At the same time, the practice reviewedthe records of other patients who had been prescribed the

same medication. This and all other recorded incidentsand significant events were discussed at practice meetings.This included reviewing progress made on actions that hadarisen from previous incidents.

During our inspection, we saw the practice had learnedfrom the incidents and significant events that hadoccurred. Findings and conclusions had been shared withrelevant staff and all staff we spoke with, both clinical andnon-clinical, knew the reporting procedure.

We also saw the practice discussed national patient safetyalerts in staff meetings, along with any action to take as aresult of each safety alert. At the time of our inspection, anational patient safety alert had been issued regardingrecognising the early stage symptoms of Ebola and we sawevidence this had been discussed with staff.

Reliable safety systems and processes includingsafeguardingDr Arshad Khan had appropriate procedures in place toensure any risks to vulnerable children, young people andadults were identified and any action required was carriedout in a timely way. All staff we spoke with fully aware ofthese procedures and knew what they should do when asituation occurred. They had a knowledge of who theincident should be reported to within the practice, of thedocumentation that needed to be completed and of therelevant agencies that needed to be contacted, both withinworking hours and out of office hours. We saw relevantcontact details were clearly available and these wereregularly reviewed to ensure they were correct. The GPdiscussed the system used to highlight vulnerable patientson the practice’s patient records.

All staff we spoke with knew how to recognise signs ofpotential abuse in older people, adults and children. Wealso asked staff about the training they had received. Whenwe reviewed the training records held by the practice, wefound all staff had received appropriate training insafeguarding that was specific to their individual role withinthe practice. The role specific training included the practiceGP who was safeguarding lead. The practice coulddemonstrate they had the necessary training to enablethem to carry out this role and showed us relevant trainingcertificates.

Are services safe?

Good –––


The practice was also able to us they had a good workingrelationship with relevant safeguarding partner agencies,such as the Warwickshire County Council’s Social Servicesdepartment. We saw all safeguarding concerns had beendiscussed a monthly multi-disciplinary team meeting.

There was a chaperone policy in place for patients andstaff. A chaperone is a person who acts as a safeguard andwitness for a patient and health care professional during amedical examination or procedure. Notices about this wereclearly displayed for patients to see within the waitingroom and in consulting rooms. All nursing staff had beenfully trained to act as chaperones and those we spoke withcorrectly described their responsibility. The practice hadcompleted chaperone audits in 2012 and 2014 and was dueto repeat the exercise later in June 2015. This was to ensurechaperones were provided when requested, that stafftraining remained up to date and the duties had beencarried out correctly to patients’ satisfaction. Results fromthe audits carried out in 2012 and 2014 demonstrated thepractice had met the requirements.

Medicines managementWe saw that all medicines stored within the treatmentrooms and medicine refrigerators were correctly andsecurely stored. This included ensuring medicines werestored at the correct temperature. Procedures were inplace to govern this and the medicines refrigerator had itstemperature checked and recorded on a daily basis in linewith this procedure. Guidelines were also in place to detailaction to be taken if a power failure occurred. There werealso procedures in place to ensure medicines were withintheir expiry date and suitable for use. All the medicines wechecked were within their expiry dates. Expired andunwanted medicines were disposed of in line with wasteregulations. The practice did not hold stocks of controlleddrugs. Medicines were only accessible to appropriate staffand we saw training records to confirm staff had receivedappropriate medicines management training whennecessary.

Vaccines were administered in accordance with directionsthat had been produced in line with legal requirements andnational guidance. There was also a system in place for themanagement of high risk medicines, which includedregular monitoring in line with national guidance. Nostocks of controlled drugs were held.

During our inspection, we saw records of practice meetingsthat noted the actions taken in response to a review of

prescribing data. The practice is part of the GodivaPrescribing Quality Programme, in which practices worktogether to reduce prescribing levels of certain medicines,e.g. blood thinning medicines. As a result the practice hadbeen able to reduce prescribing of certain medicines in linewith medical guidelines more effectively. It is currently atposition 26 the Coventry and Rugby CCG prescribingindicators dashboard out of 79 practices within the CCG, animproved position from where it was two years ago.

The GP told us how all prescriptions were reviewed andsigned by the GP before they were given to the patient.Blank prescription forms were stored in line with nationalguidance as these were tracked through the practice andkept securely at all times.

Cleanliness and infection controlThe practice had appropriate infection control proceduresin place. This included the infection control policy andsupporting policies for areas such as the safe use anddisposal of sharps; use of personal protective equipment(PPE); management of spills of blood and bodily fluid. Thisenabled staff to plan and implement measures for infectioncontrol within the practice and effectively assess risks topatients and staff. To enable this to be carried out, apractice nurse had been appointed as the lead for infectioncontrol. They had received relevant training for this rolewhich enabled them to provide advice on infection controlmeasures within the practice and provide training to staff.We looked at training records. They demonstrated all staffhad received role specific induction training aboutinfection control, followed by ongoing training and updateswhen required.

We looked at the infection control audit that had beencarried out by the infection control lead in January 2015.This had also been undertaken annually in previous years.Any improvements identified for action had beencompleted on time. Following the latest audit, the decisionhad been taken to remove children’s toys from the waitingroom due to the increased risk of infection during the fluseason. Minutes of practice meetings showed the findingsof the audits were discussed.

Arrangements were in place to ensure the safe disposal ofclinical waste and sharps, for example, needles and blades.We saw evidence that their disposal was arranged throughan appropriate company.

Are services safe?

Good –––


During our inspection we noted the premises were visiblyclean and tidy. Cleaning schedules were in place andcleaning records were kept. The practice employed its owncleaner. Patients we spoke with told us they always foundthe practice to be clean and tidy. We saw notices abouthand hygiene techniques were displayed in staff andpatient toilets. Hand washing sinks with hand soap, handgel and hand towel dispensers were also available intreatment rooms.

There was a policy in place for the management, testingand investigation of legionella, this is a germ found in theenvironment which can contaminate water systems inbuildings. We saw records that confirmed the practicecarried out annual checks in line with this policy to reducethe risk of infection to staff and patients.

EquipmentWe observed that staff had relevant equipment to enablethem to carry out diagnostic examinations, assessmentsand treatments. Staff we spoke with explained allequipment was tested and maintained regularly. We alsosaw equipment maintenance logs and records to confirmthis. Portable electrical equipment was regularly tested. Atesting schedule was in place and appliances displayedstickers indicating the last testing date, April 2014.

Staffing & RecruitmentThe practice had appropriate measures in place to ensurethere were sufficient numbers of suitably qualified, skilledand experienced staff on duty. A weekly staff rota wascompiled several weeks in advance. This took account ofany additional staffing requirements that might be needed,for example, immediately following a bank holiday or whenstaff were on annual leave. There was always a member ofclinical staff on duty when the practice was open. Mostadministrative staff were also part time; this ensured staffcover was available if a team member was unexpectedlyabsent. We looked at procedures in place at the practice forstaffing. This included sickness and disciplinary processes.

Practice staffing was also reviewed to take into account theneeds of the local population and ensure sufficient staffwere available to meet demand. Staff we spoke withconfirmed this was the case and most patients we spokewith told us they could usually get an appointment whenthey needed one.

Management told us that in the event of a shortage of GPs,a locum GP could be used, although this had not been

necessary so far. However, a female locum GP waspermanently directly employed by the practice to providefemale GP cover. A shortage of GPs was also one of the riskscovered by the practice business continuity plan. Thiswould help to ensure sufficient GPs were available tocontinue to meet the needs of the practice patients.

The practice had a suitable recruitment policy in place. Thisgave details of the pre-employment checks the practicehad to carry out on a successful applicant before thatperson could start work in the practice. They includedchecks on identification, references and a criminal recordcheck with the Disclosure and Barring Service (DBS). Allstaff, including administrative staff, were DBS checked.

During our inspection we looked at a selection of staff filesfor a GP, administrative staff and nurses. The records weviewed demonstrated the recruitment procedure had beenfollowed. However, one of the staff files did not containevidence of identity as required under current legislation.We were told by management and administrative staff thatthe practice had a consistent and long serving staff teamand did not often need to recruit.

Monitoring safety and responding to riskThe practice carried out regular checks of the building,medicines management, staffing, dealing withemergencies and equipment. These were part of theprocedures the practice had put in place under its healthand safety policy to ensure all risks to patients and staffwere identified and effectively monitored.

Each risk was assessed, recorded in a risk log and ratedwith appropriate actions recorded to reduce and manageeach risk. We saw that identified risks were discussedduring staff meetings. We also saw staff were able toidentify and respond to changing risks to patients includingdeteriorating health and well-being or medicalemergencies.

We saw appropriate information about health and safetywas clearly displayed for all staff to see and the practicemanager was the designated health and safetyrepresentative and had received training for this additionalduty.

Arrangements to deal with emergencies and majorincidentsDr Arshad Khan had appropriate arrangements in place tomanage emergencies. For example, we saw records held bythe practice that showed all staff had received training in

Are services safe?

Good –––


basic life support. There was emergency equipment wasavailable within the practice. This included oxygen and anautomated external defibrillator, which was used toattempt to restart a person’s heart in an emergency. Staffwe spoke with knew where this equipment was kept,records indicated it was checked regularly and we sawrecords to confirm staff had been trained to use it.

There were emergency medicines kept in a secure area ofthe practice. Staff knew the location. We saw medicineswhich included those for the treatment of cardiac arrestand anaphylaxis (an allergic reaction). The practice hadprocesses in place to check whether emergency medicineswere within their expiry date and therefore suitable for use.We checked the dates on a selection of the medicines andfound they were in date and fit for use.

The practice had a business continuity plan in place whichwas regularly reviewed in the light of any changingcircumstances. This dealt with emergencies that couldimpact on the daily running of the practice, for examplepower failure, adverse weather, including flooding,unplanned sickness and access to the building. An annualfire risk assessment had also been carried out. Thisincluded actions required to maintain fire safety. If thepractice building was unavailable, we saw arrangementswere in place for the use of alternative local premises, acommunity centre.

Are services safe?

Good –––


Our findingsEffective needs assessment, care & treatment inline with standardsWe saw the practice had appropriate systems in place toassess the needs of patients and then deliver care andtreatment in line with medical guidelines and the wishes ofthe individual patient. Guidance issued by the NationalInstitute for Health and Care Excellence (NICE) were usedby clinical staff during the diagnosis and treatment ofpatient’s medical conditions. This ensured patientsreceived care based on the latest medical evidence and upto date tests and treatments.

Patients we spoke with and patients who completedcomment cards were satisfied with the care they receivedfrom Dr Arshad Khan. This included any follow uptreatment needed after their initial appointment. Patientstold us GPs were professional and sympathetic. We werealso told that practice staff provided excellent care.

We were shown how the practice had identified anddiscussed concerns that arose from an increase in theprescribing of a particular sleeping tablet. The prescribingof this medicine was in line with other practices in the area.The GP attended a workshop organised and hosted byanother local practice in April 2014 and has since recordeda 27% reduction in the usage of this medication since April2014. The practice is now below the average for prescribingit within the Coventry and Rugby Clinical CommissioningGroup (CCG) and within England.

Clinical staff managed the care and treatment received bypatients with long term conditions. Appropriate systemswere in place to ensure such patients were reviewed atleast annually. Conditions included diabetes, asthma andhypertension (high blood pressure). Out of the patient listof 3,520 patients, the most vulnerable 2% had care plans inplace in line with NHS guidelines. The lead GP explainedhow the practice liaised with care homes and carers ifpatients were admitted to care homes or neededdomiciliary care put in place to enable them to continue tolive in their own homes. Patients who required palliativecare (care for the terminally ill and their families) wereregularly reviewed.

Management, monitoring and improving outcomesfor peopleThe practice used completed clinical audit cycles tomonitor its performance with patients and identify areasthat needed to be improved. The practice had set dates torepeat these audits to ensure improvements werecontinuously being made. Some of this assessment wasundertaken for the Quality and Outcomes Framework(QOF). This is an annual incentive programme designed toreward doctors for implementing good practice. We sawevidence the practice had improved its performance inrecent years. For example, at the time of our inspection, ithad achieved a total of 94.3% of the total available pointsunder QOF. In 2011-2012, the practice had scored 82.4%.

Examples of completed clinical audits included minorsurgery and patients who required chaperones. This hadbeen undertaken in 2012 and 2014 and was due to becompleted again in June 2015. This was carried out in thecontext of the lead GP being male and the practice had alarge number of female patient appointments, not all ofwhich could be covered by the appointment timesavailable with the female locum GP. This was to ensurechaperones were provided when requested, that there wasno reduction in chaperone usage, that staff trainingremained up to date and the duties had been carried outcorrectly to patients’ satisfaction. The practice is currentlyat position 26 the Coventry and Rugby ClinicalCommissioning Group (CCG) prescribing indicatorsdashboard out of 79 practices within the CCG, an improvedposition from where it was two years ago.

The practice had developed a partnership with anindependent health provider to examine and reviewpatients with asthma and Chronic Obstructive PulmonaryDisease (COPD), a lung condition. This had resulted inadditional patients being called to the practice for reviewwhen they had been identified as moderate or severe.

We were satisfied the practice identified and tookappropriate action when areas of concern were identified.For example, the higher than average number of patientswho were prescribed sleeping tablets. The practice workedwith other neighbouring local practices to identify andreduce this, an example of how the practice worked withother practices to share training and best practice. As aresult, the practice had seen a significant reduction in theprescribing of these medicines. The specific needs of thelocal population were also identified as there was a high

Are services effective?(for example, treatment is effective)

Good –––


rate of cardiovascular disease, hypertension and strokes,usually found in an area with a high ethnic populationgroup. The practice had carried out work to identify andtreat patients with such conditions at an early stage. It wasplanned to undertake clinical audits of this later in 2015 todetermine the benefit to patients.

Effective staffingThe practice staff included medical, nursing, managerialand administrative teams. During our inspection we lookedat a range of staff training records. It was clear staff were upto date with training, for example, in basic life support andsafeguarding. We saw GPs were up to date with their yearlycontinuing professional development requirements. All GPshad either been revalidated or had a date for revalidation.(Every GP is appraised annually and undertakes a fullerassessment called revalidation every five years. Only whenrevalidation has been confirmed by the General MedicalCouncil can the GP continue to practise and remain on theperformers list with NHS England). Staff also had annualappraisals. These were used to identify training needs andaction plans were formed. Staff we spoke with confirmedthe practice provided training and funding for relevantcourses. Training was prioritised.

Nursing and staff had detailed job descriptions and thepractice was able to demonstrate they were trained to carryout these duties. For example, administration of vaccines.We were shown certificates to demonstrate that they hadappropriate training to fulfil these roles.

Working with colleagues and other servicesThe practice worked closely with other services to ensurepatients’ needs were met and more complex medicalneeds were effectively managed. This included the receiptof blood test results, X-rays results and information fromthe local hospital and out-of-hours GP services, for exampledischarge summaries and records of treatment. Identifiablestaff read and acted on this information when it wasreceived. Staff concerned understood their roles.

Records confirmed the practice worked closely with thecommunity midwife service, health visitors, communitymental health professionals and community drug teams.Patients were referred to local clinics for blood testing,chiropody and anti-coagulant (blood thinning) testing.

There were integrated team meetings held every one ortwo months to discuss concerns. This included the needsof complex patients, for example those with end of life care

needs or children on the at risk register. These meetingswere attended by district nurses, social workers, palliativecare nurses and decisions about care planning weredocumented. We saw minutes of these meetings andevidence that clinical updates, significant events andemergency admissions to hospital were discussed andactions identified. We saw that some meetings had missinginformation about which staff members attended themeetings, decisions taken and which staff members wouldbe responsible for any actions.

The waiting room contained a large selection of leafletsabout locally available services. Most of these wereavailable in the other languages represented within thelocal community. Relevant information was also displayedon a large screen computer monitor within the patientwaiting room, this was also multi-lingual.

Information sharingPractice staff used an electronic patient record todocument and manage patient’ care. The package enabledscanned paper communications, such as those fromhospital, to be saved in the system for future reference. Allstaff were fully trained on this.

The practice used recognised electronic systems to sharecommunications with other organisations. As an example,there was a shared system with the local GP out-of-hoursprovider. This ensured patient data was shared in a secureand timely way. The practice received details of allout-of-hours attendances before 8am on the next workingday in line with national guidance. A system was also inplace for making referrals, and the practice made most ofits referrals through the Choose and Book system. (TheChoose and Book system enables patients to choose whichhospital they will be seen in and to book their ownoutpatient appointments in discussion with their chosenhospital).

Consent to care and treatmentThe practice had a process to ask for, record and reviewconsent decisions that were needed from patients. We sawthere were consent forms for patients to sign agreeing tominor surgery procedures. We saw that the need for thesurgery and the risks involved had been clearly explainedto patients. Some patients we spoke with confirmed this.

Processes included one to obtain signed consent forms forchildren who received immunisations. Information wasalso available about of potential side effects of


Good –––


immunisations. The practice nurse recognised the need toobtain consent from parents and what to do if consent wasneeded when a parent wasn’t available. The GP and nurseswe spoke with demonstrated a clear understanding of theimportance of determining if a child was Gillick competentespecially when providing contraceptive advice andtreatment. A Gillick competent child is a child under 16 whohas the legal capacity to consent to care and treatment.They are capable of understanding the implications of theproposed treatment, including the risks and alternativeoptions.

Staff we spoke with showed they had an understanding ofthe Mental Capacity Act 2005 and appropriate knowledgeabout best interest decisions for patients who lackedcapacity. Mental capacity is the ability to make an informeddecision based on understanding a given situation, theoptions available and the consequences of the decision.People may lose the capacity to make some decisionsthrough illness or disability.

When patients needed an interpreter, practice staff wereusually able to interpret as most staff were multi-lingual.When this wasn’t possible, the practice could use aninterpretation service.

Health Promotion & PreventionThe practice offered NHS health checks to all its patientsaged between 40 and 75 years. Since April 2014, thepractice had offered 164 NHS health checks and 88 patientshad accepted. This was slightly below the average for theCoventry and Rugby Clinical Commissioning Group (CCG)area. The practice followed up those who failed to respond.The practice’s performance for cervical smear uptake wasabove average compared to others in the CCG.

When patients registered with the practice for the first time,they were offered an appointment with a practice nurse. Ifthe practice nurse identified any medical concerns, thepatient was referred to the GP or another healthcareprofessional if more appropriate.

We were shown work the practice had carried out toidentify and promote particular health needs within thelocal community. For example, with the high local level ofdiabetes and coronary heart disease. These rates were inline with those expected within the particular ethniccommunity and with the high level of deprivation locally.Patients who smoked were referred to the smokingcessation support provided by University Hospital inCoventry.


Good –––


Our findingsRespect, Dignity, Compassion & EmpathyPatients we spoke with and patients who completedcomment cards, were happy with the care they receivedand any follow-up needed once they obtained anappointment. Patients felt they were consistently treatedwith dignity and respect by all members of staff. Most of thepatients we spoke with also commented on how friendlyand helpful all staff and GPs were. None of them madenegative comments. The GPs were also described assympathetic by patients. During our inspection we saw howstaff interacted with patients, both in person and over thetelephone. Staff were helpful and empathetic, warm andunderstanding towards patients. We saw evidence that allstaff had received customer service training in response toprevious feedback from patients.

We were told by the GP how patients’ privacy and dignitywas respected by staff during examinations. We sawcurtains could be drawn around treatment couches inconsultation rooms. This would ensure patients’ privacyand dignity in the event of anyone else entering the roomduring treatment.

The national patient survey carried out in 2014 had resultsthat were below average for the Coventry and RugbyClinical Commissioning Group (CCG). For example, 53% ofrespondents said the last GP they saw or spoke to wasgood at giving them enough time. The CCG average was86%. A total of 52% of respondents described their overallexperience of this surgery as good, against a CCG averageof 83%.

In December 2014, 85 patients completed a patient survey,issued by the practice. This was the first patient survey evercarried out by the practice and represented 2.5% of thepatient list. Of those patients who responded, 80% felt theywere treated with respect by staff; 51% were happy with the

treatment proposed by the GP; 53% were happy with theGP’s decision making and 49% were happy with theavailability of practice nurse appointments. These figureswere also below average for the CCG.

An action plan was put in place following these surveyresults. Longer appointments have been offered forpatients with chronic health conditions, additional practicenurse appointments have been made available and thepractice has increased the promotion of on-line services,such as appointment booking. Later in 2015, managementintended to review progress made with resolving theseconcerns.

Care planning and involvement in decisions aboutcare and treatmentDuring our inspection, we saw patients were givenappropriate support and information so they could makeinformed decisions about their care and treatment needs.Staff told us how this was discussed with patients beforeany treatment started and how they assessed what careand support each patient needed. When we spoke with theGP, it was explained how they discussed any proposedchanges to treatment or medication with each patient atthe time a proposed change was identified. The GPexplained how they kept patients fully informed duringconsultations and treated patients with consideration andrespect.

Patients told us they felt listened to by their GP and thepractice staff. Some patients indicated that they had longterm health conditions and said that they were seenregularly.

Patient/carer support to cope emotionally withcare and treatmentWe did not speak with or receive any comment cards frompatients who were also carers. However the GP and staffdescribed the support they provide for carers and links torefer patients to appropriate organisations, including acounselling service for professional support, this includedfamily members after bereavement.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needsDr Arshad Khan had appropriate systems in place tomonitor and maintain its service level. The practiceresponded to the needs of its patients and kept this underreview. GPs and staff understood the needs of the practicepopulation and systems were in place to address anyidentified needs in the way services were delivered. GPsprovided examples of how the practice responded to theneeds of the local community. For example, following anemphasis on identifying patients with dementia, we wereshown how the practice had increased dementia screeningand ensured ‘at risk’ patients were identified on theirpatient records. The practice is involved with the NationalEnhanced Service Dementia Identification Scheme whichhas improved the practices’ identification of patients withearly stage dementia.

The needs of patients with long term conditions were keptunder review. In 2014, a pilot scheme was organised whichsaw some diabetic patients have clinics at the practice witha diabetes consultant from George Eliot Hospital, Nuneatonto identify and improve outcomes for patients. The practicehad registers of patients with mental health support andcare needs and with learning disabilities. Each patient onthe registers was invited for an annual review. Staff told usthey had a good working relationship with the localcommunity mental health team.

We looked at minutes of meetings that discussed patientcapacity and demand. As a result, changes were made tostaffing and clinic times when required. Following thenational and local patient survey results in December 2014,the number of practice nurse appointments had beenincreased to meet an increase in demand. Services werealso reviewed in the wider context of the local healthcommunity. Review meetings were held with the ClinicalCommissioning Group (CCG) and a GP attended these.

The practice had an established Patient ParticipationGroup (PPG). The purpose of the PPG was to act as anadvocate on behalf of patients when they wished to raiseissues and to comment on the overall quality of the service.This ensured that patients’ views were included in thedesign and delivery of the service. We saw how the PPGplayed an active role and was a key part of the

organisation. Regular meetings were held. We saw how thePPG had been involved with promoting the recent patientsurvey and the formation of the practice action plan whichfollowed it.

Tackling inequity and promoting equalityOf the patients who used Central Medical Centre, 70%spoke English as their secondary language. All GPs andadministrative staff were multi-lingual, so could easily havea conversation with patients. We saw that informationleaflets were available in a variety of languages in thewaiting room, as was the information displayed on thevisual display unit in the waiting area.

There was an induction loop to help patients who usedhearing aids and staff could also take patients into aquieter private room to aid the discussion if required.

Access to the serviceThe practice opened from 8am to 6.30pm every weekday,except on Thursdays when it closed at 1.30pm. Cover wasprovided by the out of hours service during this time andwas accessible by patients telephoning the NHS 111service. GPs and patients told us that if an appointmentwas needed in an emergency and all the appointment slotswere full, additional appointments were made on the sameday to ensure all patients who required an urgentappointment were seen. Telephone consultations werealso available. Following the national and local patientsurvey results in December 2014, the number of practicenurse appointments had been increased to meet anincrease in demand. Outside of these times and during theweekend, an out of hours service was provided by anotherorganisation and patients were advised to call the NHS 111service. This ensured patients had access to medical adviceoutside of the practice’s opening hours. Additionally, thepractice was within walking distance of a frequent directbus journey to the local walk in centre.

Appointments could be booked for the same day, for withintwo weeks’ time or further ahead. Patients could makeappointments and order repeat prescriptions through anon-line service. Home visits were available for patients whowere unable to go to the practice.

The information from CQC comment cards and patients wespoke with indicated that the service was easily accessibleand that patients were always able to get an appointmenton the same day they phoned if this was needed. Followingthe 2014 national patient survey results which showed

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


43.3% of patients found it easy to get through to thepractice on the telephone, the practice made changes to itstelephone system and in conjunction with the PPG,improved and put an increased emphasis into its on-lineservices.

Listening and learning from concerns & complaintsThe practice received and acted upon concerns andcomplaints from patients. This was in line with guidelinesand contractual obligations issued for all GPs in England.The practice manager handled all complaints in thepractice. The complaints procedure was clearly displayedwithin the waiting room, along with clear information onhow a patient could make a complaint if they wished to doso. This was also printed within the patient informationpack. All the patients we spoke with said they had neverhad to raise a formal complaint. It was clear that verbalcomplaints were dealt with in the same way as writtenones. The practice manager told us, if a patient telephoned

the practice to complain, they would immediately take thecall if available and attempt to resolve the concernsimmediately if possible. The practice compiled acomplaints summary which summarised the complaintsfor each year which was used to identify any trends.

During our inspection, we looked to see whether thepractice adhered to its complaints policy. Three complaintshad been received within the last 12 months. None relatedto safety incidents and there were no re-occurring themes.We found that the complaints had been dealt withappropriately and within the timescales set out in thepractice’s complaints policy. One complaint related to aperceived delay with a repeat prescription. Following this,the practice clarified its procedure requiring 48 hours’notice for a repeat prescription and made an improvementto its website to make this clearer when repeatprescriptions were ordered on-line.

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


Our findingsVision and StrategyThe practice aimed to provide ‘a friendly and caringservice’. We saw this was referred to on the practice websiteand in the patient information leaflet produced by thepractice. Staff we spoke with mentioned it during ourdiscussions with them. During these discussions it becamehighly evident that staff intended to give patients a safe,caring service where patients were treated with dignity andrespect. Staff understood the values held by the practiceand put them into practice as they carried out their dailyroles.

The GP partners held quarterly partners’ meetings outsideof surgery opening times. We looked at minutes of some ofthese meetings and saw they discussed topics such asforward planning, practice objectives, future direction andvision. The practice regularly reviewed its objectives duringstaff meetings. The lead GP told us the practice aimed toprovide a high standard of evidence based medical care.

GPs and management demonstrated how they wanted tobe involved with clinical initiatives and had pursuedopportunities when time and resources allowed. Forexample, the practice is involved with the NationalEnhanced Service Dementia Identification Scheme whichhas improved the practices’ identification of patients withearly stage dementia.

Governance ArrangementsThe practice used information from a variety of sources tohelp them assess and monitor their performance. Thisincluded information from their Quality and OutcomesFramework (QOF) results and the Clinical CommissioningGroup. QOF is an annual incentive programme designed toreward doctors for implementing good practice. Thepractice had improved their performance within theCoventry and Rugby Clinical Commissioning Group (CCG)for the Quality and Outcomes Framework (QOF). As a resultits performance was now above average for the CCG,having been below average two years ago.

The lead GP had lead roles with specific areas of interestand expertise. This included governance with a clearlydefined lead management role and responsibility. Duringthe inspection we found that all members of the team wespoke with understood these roles and responsibilities. Thepractice held a regular meeting of clinical staff, this

included discussions about any significant event analyses(SEAs) that had been completed. All of the clinical staffattended these meetings and where relevant, other staffalso took part in the discussions about SEAs. This helped tomake sure that learning was shared with appropriatemembers of the team. GPs also met regularly to discussclinical and governance issues.

Leadership, openness and transparencyDr Arshad Khan was a sole lead GP who had previouslyworked as part of a partnership. Some of the staff team hadworked together over a number of years. They weresupported by a practice manager who staff described asbeing very approachable. The staff we spoke with told usthe practice was a good place to work where they weresupported and valued by management.

Practice seeks and acts on feedback from users,public and staffThe practice had a Patient Participation Group (PPG). Thismet every three months. The purpose of the PPG was to actas an advocate on behalf of patients when they wished toraise issues and to comment on the overall quality of theservice. This ensured patients’ views were included in thedesign and delivery of the service. We saw minutes ofprevious PPG meetings and saw how the PPG has beenfully involved in initiatives such as the first patient surveywhich had been carried out in December 2014 and in theformation of the action plan which followed this survey andthe national patient survey carried out during the sameyear.

All the patients we spoke with on the day of our inspectiontold us they were happy with the service they received fromthe practice. The practice had closely monitored patientcomments and had action plans in place following thepatient surveys carried out in 2014. For example, thepractice had provided customer care training for all staffand the number of appointments available with thepractice nurses has also been increased as a result ofcomments from patients. We saw that the practice hadplans in place to repeat the patient survey later in 2015 andin future years and make appropriate changes to the actionplan as improvements were identified or other areas ofpatient concern were raised. All staff were fully involved inthe running of the practice. We saw there weredocumented staff meetings every two months.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Good –––


Management lead through learning &improvementWe saw evidence that the practice was focussed on quality,improvement and learning. The whole practice team hadsessions each year for ‘protected learning’. This was usedfor training and to give staff the opportunity to spend timetogether. For example, within the last 12 months,safeguarding and customer service training had beencarried out. Clinical staff had protected learning time for

training, which had included disease management forolder people, prescribing management and gynaecology.Best practice was discussed and shared with colleaguesfrom other practices.

The results of significant event analyses and clinical auditcycles were used to monitor performance and contributeto staff learning.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Good –––
