Dr Joann Amin Also known as The Willows Surgery

We carried out an announced inspection at Dr Joann Amin on 22 July 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective – requires improvement

Caring – good (rating awarded at the inspection 24 May 2016)

Responsive – good (rating awarded at the inspection 24 May 2016)

Well-led – requires improvement

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

Why we carried out this inspection/review (delete as appropriate)

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach. This inspection was a focused inspection looking at the key questions Safe, Effective and Well-led.

How we carried out the inspection/review

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 remotely and on site.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records remotely to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit
• Gaining feedback from staff by using 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 have rated this practice as Requires Improvement overall

We found that:

Following this inspection, we have rated the practice requires improvement for providing safe services. We identified the following areas of concern:

• Recruitment checks were not always carried out in accordance with regulations.
• The practice did not hold appropriate emergency medicines, have risk assessments in place to determine the range of medicines held, or an effective system in place to monitor stock levels and expiry dates.

Following this inspection, we have rated the practice requires improvement for providing effective services. We identified the following areas of concern:

• The practice was unable to demonstrate that some clinical staff had the skills, knowledge and experience to carry out their roles.

Following this inspection, we have rated the practice requires improvement for providing well-led services. We identified the following areas of concern:

• The practice had not identified the actions necessary to address challenges to quality and sustainable care.
• The practice did not always have clear and effective processes for managing risks, issues and performance.
• Some governance and assurance systems were not effective.
• There were limited systems and processes for learning, continuous improvement and innovation.

We found two breaches of regulations. The provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed. Ensure where appropriate, persons employed are registered with the relevant professional body.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Involve staff in the development of the vision, values and strategy of the practice.
• Continue to establish a patient participation group.
• Establish a quality improvement programme.
• Ensure clinical staff receive copies of practice meeting minutes when they cannot attend.

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