The Care Quality Commission
  • Doctor
  • GP practice

Dr Azim Khan Also known as Unity Surgery

Overall: Requires improvement read more about inspection ratings

Unity Surgery, 318 Westdale Lane, Mapperley, Nottingham, Nottinghamshire, NG3 6EU (0115) 987 7604

Provided and run by:
Dr Azim Khan

Important: We are carrying out a review of quality at Dr Azim Khan. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

25 April 2023

During a routine inspection

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

10 November 2022

During an inspection looking at part of the service

We carried out an announced focussed inspection at Dr Azim Khan (also known as Unity Surgery) 9 and 10 November 2022 to review compliance with a Warning Notice which was issued following our previous inspection on 5 and 21 July 2022.

In July 2022, the practice was rated as inadequate overall and for the key questions of safe, effective and well-led. The practice was placed into special measures.

This inspection on 9 and 10 November 2022 was undertaken to review compliance with the warning notices which had to be met by 1 October 2022, but the inspection was not rated.

The ratings from July 2022 therefore still apply and will be reviewed via a further inspection to take place within the next six months.

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

The ratings for each key question are;

Safe - Inadequate

Effective - Inadequate

Well-led – Inadequate

Why we carried out this inspection.

This inspection was a focused inspection to follow up on the Warning Notice issued in connection with breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2104.

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:

  • 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.
  • A shorter site visit.

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.
  • information from the provider, patients, the public and other organisations.

We have not rated this practice as the rating remains unchanged until we have completed a further inspection incorporating all relevant key questions.

We found that action had been taken to address the breaches identified in the warning notice and it was evident that improvements had been made.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had taken reasonable steps to protect patients and others from the risks posed by healthcare associated infections.
  • The provider had implemented effective oversight of the systems and processes designed to deliver safe and effective care.
  • Patients requiring high dose steroid treatment for severe asthma episodes were not always followed up in line with national guidance to ensure they received appropriate care.
  • We had concerns regarding the potential over prescribing of SABA inhalers.

The provider must:

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

We have issued the provider with a Requirement Notice for a breach of Regulation 12 (1)(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

21 July 2022

During an inspection looking at part of the service

We carried out an announced inspection at Dr Azim Khan on 5 and 21 July 2022. Overall, the practice is rated as Inadequate.

The ratings for each key question are;

Safe - Inadequate

Effective - Inadequate

Well-led – Inadequate

We had last inspected the practice on 1 December 2017 when it was rated Good.

Why we carried out this inspection.

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 on the safe, effective and well-led key questions.

This inspection was a focused review of information:

  • We reviewed the key questions of safe, effective and well-led in line with our inspection methodology.
  • The ratings for the caring and responsive key questions were carried forward from our previous inspection as we had no concerns to indicate that these needed to be reviewed.

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
  • 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
  • A shorter site visit
  • Receiving written staff feedback prior to the on-site inspection taking place

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 did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • Patients did not always receive effective care and treatment that met their needs.
  • The practice had not taken reasonable steps to protect patients and others from the risks posed by healthcare associated infections.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patients could access care and treatment in a timely way.
  • The provider did not have effective oversight of the systems and processes designed to deliver safe and effective acre.

The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

16 November 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Azim Khan on 28 April 2016. During that inspection we found that not all staff who undertook chaperone duties had received formal training to carry out the role, and the practice had not obtained a disclosure and barring service (DBS) check for one member of staff. Also, effective systems were not in place to oversee and improve the quality and safety of the services provided including the prevention and control of infection. Not all areas of the premises were clean and hygienic.

In view of the above the practice was rated as requires improvement for providing safe and well-led services.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Azim Khan on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice told us what action they had, and were taking to meet the legal requirements in relation to the breaches.

We undertook a focused inspection on 16 November 2016 to check that the provider had completed the required action, and now met the legal requirements. We visited the practice as part of this inspection.

This report covers our findings in relation to the above requirements. This inspection found that the provider had taken appropriate action to meet the legal requirements.

  • Staff who undertook chaperone duties had received  formal training to carry out the role, and the practice had obtained a disclosure and baring service check for all staff. (These checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with vulnerable children or adults).
  • Systems were in place to manage the prevention and control of infection, and to ensure the premises were kept clean and hygienic.
  • Effective systems were in place to oversee and improve the quality and safety of the services provided, and to reduce risks to patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Unity Surgery on 28 April 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. However, not all risks to patients had been identified, and the systems and processes in place were not implemented well enough to be effective at mitigating risk.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice’s Quality Outcomes Framework (QOF) performance was variable with exception reporting in some areas being higher than local and national averages.
  • Most patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The majority of patient feedback which included the National GP Patient Survey rated the care provided as good.
  • Information about services and how to complain was available and easy to understand. The practice maintained a system for addressing, investigating and responding to complaints received. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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 equipped to treat patients and meet their individual needs.
  • There was a leadership structure and staff felt supported by management. However, not all staff were aware of the practice’s mission statement and strategic objectives.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • The provider must ensure the arrangements in place for identifying, assessing and mitigating risk are effective in relation to non clinical staff undertaking chaperone duties. This includes assessment of whether staff should undertake chaperone duties before disclosure barring service checks are completed and delivering training for chaperones.

  • The provider must implement effective systems to ensure safe patient care. The provider must do all that is possible to mitigate risks by preventing and controlling the spread of infection.

The areas where the provider should make improvements are:

  • Strengthen the systems for monitoring blank prescriptions.

  • Ensuring procedures for dealing with emergencies on site are robust.

  • Ensuring a co-ordinated and managed approach is adopted for the distribution of medicines alerts within the practice reflecting actions taken to ensure patient safety.

  • Taking appropriate action to reduce the high exception rate reporting in some clinical indicators.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 June 2013

During a routine inspection

We found the service to be welcoming with friendly staff. Information was displayed for people using the service, including health promotion, access to support services, information about the practice and other services available. There was a touch screen booking in facility in the waiting area and appointments could be made on line using the practice website. Translations facilities were available if required.

We spoke with seven patients who all spoke highly of services provided to them. We also spoke with staff who said they enjoyed working in the practice and felt supported in their work.

Patients' needs were assessed and care and treatment was planned and delivered in line with their individual wishes. One patient said, "I've always been treated well here." Another patient said, "All the staff; the doctor, nurses and receptionists are very courteous."

Staff had received training in safeguarding children and were knowledgeable about safeguarding vulnerable adults procedures. They were aware of the systems to refer safeguarding concerns to ensure that patients were protected from risks of harm.

We found that space at the premises was restricted and presented some challenges to both staff and patients. The provider had made some adaptations to enable disabled people to have equal access.

We found that improvements were required to ensure confidentiality of record keeping. The practice manager agreed to address this without delay.