The Care Quality Commission
  • Doctor
  • GP practice

Blurton Medical Practice Also known as Practice of Dr J A Mir

Overall: Good read more about inspection ratings

Blurton Health Centre,, Ripon Road, Blurton,, Stoke On Trent, Staffordshire, ST3 3BS (01782) 319375

Provided and run by:
Blurton Medical Practice

All Inspections

30 September 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Blurton Medical Centre on 28 and 30 September 2022. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe, effective and well-led. Due to assurances we received from our review of information, we carried forward the ratings for the following key questions: caring and responsive from our last inspection in June 2019.

Overall, the practice is rated as good.

Safe - Requires improvement

Effective- Good

Caring -Good

Responsive – Good

Well-led - Good

Following our previous inspection on 17 June 2019, the practice was rated good overall and for effective, caring, responsive and well-led key questions but requires improvement for providing safe services. We found the areas identified for improvement at the last inspection had been met.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

  • The issues identified in the inspection in June 2019.
  • Key questions safe, effective and well-led.
  • Follow up on a Requirement Notice breach in Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.
  • Three best practice recommendations.

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.
  • Staff questionnaires.

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:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We have rated this practice requires improvement for providing safe services. This is because:

  • The clinical searches identified deficiencies in the system of responding to historic patient safety alerts.
  • We found there were some gaps in the management of patients who required regular monitoring and reviews.

We found a breach of regulations. The provider must:

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

The provider should:

  • Implement a strategy to improve, where able, the uptake of the aged five year olds childhood vaccinations and of cervical screening.
  • Implement clinical audit second cycles to demonstrate if improvements and changes in practice had improved patient outcomes and become embedded in practice.
  • Consider a review of the occupational health documentation to be assured that the information in their fit for role statement contains full immunisation and vaccination histories for all staff.
  • Consider an induction system for temporary nursing staff tailored to their role.
  • Formalise the non-medical prescriber competency and supervision sessions.
  • Consider a review of the practice DNACPR record keeping processes.
  • Consider implementing a measurement of the progress made against their practice strategy.

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

17 June 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Blurton Medical Practice on 17 June 2019 as part of our inspection programme to follow up on the breach in regulation identified at our previous inspection which took place in August 2017. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for Blurton Medical Practice on our website at www.cqc.org.uk.

At the last inspection in August 2017 we rated the practice as requires improvement for providing a well led services because:

  • The practice needed to ensure that accurate, complete and contemporaneous records are maintained securely in respect of each service user. In particular around the recording of significant events and the review of correspondence.
  • The practice needed to ensure staff received regular performance reviews.
  • Keep its protocol to follow-up on medical alerts such as the Medicines and Healthcare products Regulatory Agency (MHRA) under review to ensure it is effective.
  • Keep a formal record of all practice meetings.
  • Carry out an annual review of patients with a learning disability.

We carried out an announced focused inspection on 17 June 2019 to ensure that the issues identified had been addressed. At this inspection, we found that the provider had satisfactorily addressed these areas.

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.

We rated the practice as requires improvement for providing safe services because:

  • There were gaps in monitoring patients’ health in relation to those found to have blood test results within a pre-diabetes range. Patients prescribed and monitored for medicines in secondary care did not have these medicines recorded in their hospital prescribed medicines section in their electronic records.
  • There was a lack of risk assessments for emergency medicines not held at the practice.
  • There was a lack of comprehensive oversight on the NHS Property Management risk assessments for the premises.
  • There was a lack of staff awareness and training on the practice business continuity plan.

We rated the practice as good for providing effective services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.

We rated the practice as good for providing a well led service because:

  • The practice had developed an action plan to meet the needs of its registered population whilst bearing in mind the aims and objectives of the wider health economy.
  • Identified gaps in the practice governance processes had been proactively managed to reduce risk and to develop sustainable care, we did however identify a few gaps which did require improved governance.

These areas affected all population groups, so we rated all population groups as good, except for families, children and young people which was rated requires improvement in effective and therefore rated as requires improvement overall.

The areas where the provider must make improvements are:

Ensure care and treatment is provided in a safe way to patients. In particular:

  • Implement an effective monitoring process for patients’ health in relation to those found to be within a pre-diabetes range.
  • Document secondary care prescribed medicines within the patients’ hospital prescribed medicines section in their electronic records.
  • Complete risk assessments for emergency medicines not held at the practice.
  • Maintain clear oversight on the NHS Property Management risk assessments for the premises.

The areas where the provider should make improvements are:

  • Introduce staff training and awareness of the practice business continuity plan.
  • Encourage and improve the uptake of the childhood immunisation programme.
  • Develop and document clear vision, values and strategy.

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

9 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice


We previously carried out an announced comprehensive inspection at the Practice of Dr J A Mir on 19 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 19 September 2016 inspection can be found by selecting the ‘all reports’ link Practice of Dr J A Mir on our website at www.cqc.org.uk.

This inspection was an announced follow-up comprehensive inspection and was carried out on 9 August 2017. Overall the practice is now rated as good.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However there were gaps in some of the recording of the events and associated learning.

  • The practice had clearly defined and embedded systems to minimise risks to patient safety, but systems did not always ensure good governance.

  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

  • 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.

  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

  • 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 clear leadership structure in place.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. In particular:

  • Ensure that accurate, complete and contemporaneous records are maintained securely in respect of each service user. In particular around the recording of significant events and the review of correspondence.

  • Ensure staff received regular performance reviews

In addition the provider should:

  • Keep its protocol to follow-up on medical alerts such as the Medicines and Healthcare products Regulatory Agency (MHRA) under review to ensure it is effective.

  • Keep a formal record of all practice meetings.

  • Carry out an annual review of patients with a learning disability.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

19 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr J A Mir on 19 September 2016. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • On the whole, patients 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 the management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Develop a formalised system to act upon medicines and equipment alerts issued by external agencies, for example from the Medicines and Healthcare products Regulatory Agency (MHRA).

  • Staff must assess patients’ needs and deliver care in line with current evidence based guidance and improve the way they share and discuss changes to guidance.

In addition the provider should:

  • Risk assess the need for emergency medicines within doctors’ bags when they attendhome visits.

  • Implement a recorded and formal system of sharing updates in best practice guidelines with the staff team.

  • Take steps to identify fridge plugs so that they avoid being turned off accidentally.

  • Ensure all clinical staff are up-to-date and familiar with the relevant requirements relating to patient consent.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice