Archived: Dr Alma Sarajlic

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Alma Sarajlic, also known as Staines Road Surgery on 5 May 2016. The overall rating for the practice was good; however, we identified breaches of regulation in respect of safety, and the practice was rated as requires improvement for the safe domain. We issued a requirement notice in respect of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the practice submitted an action plan, outlining the actions they would take to address the issues identified. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Alma Sarajlic on our website at www.cqc.org.uk.

At the time of the initial inspection, the practice was undergoing a major refurbishment and was temporarily operating from porta cabins and a single room in the main building. We undertook this announced comprehensive inspection on 15 August 2017 to check that the practice had followed their plan and to confirm that they now met the legal requirements, and to check that their newly refurbished premises were compliant with regulations. This report covers our findings in relation to the follow-up inspection.

The practice is now rated as inadequate in respect of safety, and requires improvement in respect of providing effective services and being well led; the practice is rated requires improvement overall.

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

• The practice had some systems, processes and practices to minimise risks to patient safety; however, patients were at risk due to the practice’s failure to ensure that staff had the skills and competence to carry-out their roles.
• Staff demonstrated that they understood their responsibilities in relation to safeguarding children and vulnerable adults and all had received training on safeguarding relevant to their role; however, not all staff had received refresher training within the recommended timeframe.
• The practice was not always able to demonstrate how it ensured that staff were working within their scope of competence.
• There was some evidence of quality improvement; the practice had a programme of regular reviews of their lists of certain patients; however, the practice had not initiated any new clinical audits in the past year.
• The practice’s performance in respect of the delivery of care to patients and patient outcomes was largely comparable with local and national averages; however, the practice’s uptake rate for childhood immunisations was below average.
• Information about services and how to complain was available; however, some staff were unclear about the process. Improvements were made to the quality of care as a result of complaints and concerns.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events; however, whilst learning from incidents was shared with those concerned, the practice did not routinely share information and learning with the wider practice team.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. The practice scored highly for patient satisfaction in all areas. Translation services were available for patients; however, this was not advertised in the patient waiting area.
• Patients we spoke with 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 clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

• Ensure that care and treatment is provided in a safe way for service users.
• Ensure that processes are in place to assess, monitor and improve the quality and safety of service, in particular, putting in place a process of clinical audit.

In addition, the provider should:

• Ensure that all staff are clear about the practice’s significant events reporting process and complaints process, and that the learning from all incidents is shared with all staff.
• Improve the uptake of childhood immunisations.
• Advertise the availability of translation services to patients.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice