The Slieve Surgery

We carried out an unannounced focused inspection at The Slieve Surgery on 22 September 2021 in response to concerns received. The practice was registered under a new provider, Dr Imran Zaman, in March 2021.

The practice had previous been rated good at an inspection on 26 October 2016 under the previous provider, The Slieve Surgery.

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected.
• Information from our ongoing monitoring of data about services.
• Information from the provider, patients, the public and other organisations.

How we carried out the inspection:

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff and provider interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.

We have rated this practice as Requires improvement overall and good for all population groups except the population groups Families, children and young people and People whose circumstances make them vulnerable which are rated as Requires improvement.

We found that:

• The provider was not able to evidence that recruitment checks were routinely being carried out before staff commenced employment.
• Infection prevention and control was not managed effectively and areas from the practice’s audit had not been carried out. Following our inspection, the provider reviewed this.
• The practice did not operate an effective system to routinely ensure safe monitoring of patients prescribed high risk medicines as well as patients on other repeat prescriptions.
• A local care home had experienced delays in referrals for residents and was no longer using the practice.
• Governance processes were not always effective, such as those to monitor recruitment processes, oversight of medicines management and the quality of medical records.
• The provider did not demonstrate how they ensured transportation and storage of confidential health records were carried out in line with Data Protection Act 2018.
• Staff did not always feel supported and improvement was needed in the practice’s culture.

The areas where the provider MUST make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Improve the rates for child immunisations
• Improve the rates for cervical screening

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care