13 September 2019
During an inspection looking at part of the service
We carried out an announced focused inspection at Dr Mohammed Nasir Imam on 13 September 2019 as part of our inspection programme.
We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
- Are services at this location effective?
- Are services at thei location responsive?
- Are services at this location well-led?
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 and
- information from the provider, patients, the public and other organisations.
We have rated this practice as good overall and good for all population groups with the exception of the working age population group.
We found that:
- Patients received effective care and treatment that met their needs.
- The practice had a challenging population with high prevalence of diabetes. We found the practice was performing well against most patient outcome targets given the population needs.
- The practice had made positive progress to improve childhood immunisations and was achieving national targets.
- The practice had taken action to try and improve uptake of cancer screening programmes however, these were still significantly lower than local and national averages.
- Learning was encouraged and staff were given opportunities to develop the skills required for their roles and responsibilities.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The practice had taken action and made significant progress in improving patient satisfaction in relation to access to appointments.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Continue to review action taken to improve uptake of national cancer screening to ensure it is working.
- Improve the recording of discussions around end of life care.
- Formalise processes for ensuring the competence of non-medical clinical staff working in advanced roles.
- Consider including more detail in practice meeting minutes for future reference and staff not in attendance.
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