Dr Azim Khan Also known as Unity Surgery

Updated 24 August 2023

Unity Surgery is located 3 miles from Nottingham city centre at:

318 Westdale Lane,

Mapperley,

Nottingham,

Nottinghamshire

NG3 6EU

The practice provides primary medical services to approximately 4500 patients through a Personal Medical Services (PMS) contract with Nottinghamshire Integrated Care Board.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the eighth lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 92% White, 3% Asian, 2.7% Mixed, 1.9% Black and 0.92% Other.

The practice has a higher than the local and national average elderly population. The practice also has a higher number of patients with long term conditions compared to the local and national average.

The practice has one GP partner, one salaried GP and two regular locum GPs.The clinical team includes one practice nurse (29 hours per week) and two health care assistants (25 hours per week between them).

The practice also employs a practice manager, a deputy practice manager and a team of reception, clerical and administrative staff.

The practice is open from 8am each weekday until 6.30pm on a Wednesday and Thursday ,8pm on a Monday and Friday and 8.30pm on a Thursday.

The provider is registered with CQC to deliver the Regulated Activities; Diagnostic and screening procedures, Maternity and midwifery services, Family planning, the Treatment of disease, disorder or injury and Surgical procedures.

The practice is part of a wider network of GP practices known as Arrow Health Primary Care Network.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, many GP appointments were telephone consultations, although the practice had stayed open for some face to face appointments l throughout the COVID pandemic.

Out-of-hours GP services are provided by NEMS Community Benefit Services Limited (NEMS).

Updated 24 August 2023

We carried out an announced comprehensive inspection at Unity Surgery on 25 April 2023. Overall, the practice is rated as Requires Improvement.

Ratings for each key question

Safe - Requires Improvement.

Effective – Good.

Caring – Good.

Responsive – Good.

Well-led – Requires Improvement.

Following our previous inspection in July 2022, the practice was rated Inadequate overall and for the key questions Safe, Effective and Well-led.

The practice was placed in special measures and was issued with 2 warning notices in relation to breaches identified for Regulation 12 (safe care and treatment) and regulation 17 (good governance).

A follow up focussed inspection was conducted in Novemeber 2022 to review improvements made in relation to the warning notices issued for breaches of regulation 12 and 17 found at the previous inspection. We found that most of the issues had been addressed. A requirement notice was issued in relation to regulation 12 at the inspection in November 2022.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Unity Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to review special measures status and progress made in line with our inspection priorities.

• We reviewed the key questions in relation to safe, effective, responsive and well-led. In line with our current inspection schedule.During this inspection we did not review the key question relating to caring. The rating for caring has been carried forward from the previous review of the caring key question in 2016.
• Areas followed up included any breaches of regulations or ‘shoulds’ identified in previous inspection.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included :

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.
• Gathering staff feedback.
• Discussion with members of the Patient Participation Group.

Our findings

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 found that:

• Patients received effective care and treatment that met their needs.
• Patients could access care and treatment in a timely way.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

Whilst we found one breach of regulations, the provider should:

• Update the infection prevention and control action plan with further details.
• Review cleaning to ensure the patient waiting area is clean and free of debris.
• Introduce clinical supervision for registered nursing staff.
• Continue to source support and develop the knowledge and skills of the leaders within the practice.
• Introduce training on autism and learning disability.
• Continue to support staff to allow consistant identification and discussion of incidents within the practice.
• Improve the oversight of medication reviews and associated coding.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service. However, systems and processes needed further development and strengthening. A requirement notice has been issued for Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.

The practice will be kept under review and any future inspections will be carried out in line with our ongoing priority

schedule.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services