We carried out an announced focused inspection at Dr M Aslam’s Practice on 24 June 2021. Overall, the practice is rated as Good.
Safe - Requires improvement
Effective – Good
Caring - Good
Responsive - Good
Well-led – Good
We did not inspect the key questions Caring and Responsive therefore these ratings were carried over from our inspection in 2015.
Following our previous inspection on 12 November 2019, the practice was rated Requires Improvement overall and for the key questions Effective and Well led. The practice carried over the Good ratings for Safe, Caring and Responsive from our 2015 inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr M Aslam’s Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up inspection to follow up on:
- The breaches of the regulations from the last inspection.
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 interviews using video conferencing where possible and through questionnaires sent to staff.
- 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 pre and post inspection
- A site visit.
- Reviewing information we already held about the provider.
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 have rated this practice as Good overall. Specifically, Requires Improvement for Safe and Good for Effective and Well-led. We rated all the population groups as Good, except for working age people due to lower cancer screening data.
We found that:
- Some processes in place for keeping patients safe and protect from avoidable harm, required further strengthening.
- Patients received effective care and treatment that met their needs. Performance for patients with a long-term condition and those experiencing poor mental health had improved since our previous inspection.
- There was a structure in place that supported the use of data, feedback and other information, to review performance and promote quality improvement.
- There was an effective complaints system in place which followed NHS guidance.
- There was now effective oversight of areas where responsibilities had been delegated.
- There were systems in place for learning and dissemination of learning through incidents, complaints and other feedback.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
We found one breach of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
Whilst we found no breaches of regulations, the provider should:
- Improve the new system for policies and procedures once established, to check its effectiveness, also review policies and procedures generally to check that they account for staff absence and cover arrangements.
- Improve the recruitment procedure regarding the checks on immunisation of staff and implement a system for recording clinical status checks for staff.
- Continue to promote prevention activities such as cervical screening and childhood immunisations.
- Improve the timely management of pathology results
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