The Care Quality Commission
  • Doctor
  • GP practice

The Slieve Surgery

Overall: Good read more about inspection ratings

2 The Slieve, Handsworth Wood, Birmingham, B20 2NR (0121) 554 1812

Provided and run by:
Dr Imran Zaman

Important: The provider of this service changed. See old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Slieve Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Slieve Surgery, you can give feedback on this service.

7 February 2024

During an inspection looking at part of the service

We undertook a targeted assessment on 7 February 2024 of the responsive key question at The Slieve Surgery. The rating for the responsive key question is good. As the other domains were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain good.

Safe – not inspected, rating of good carried forward from previous inspection.

Effective - not inspected, rating of good carried forward from previous inspection.

Caring - not inspected, rating of good carried forward from previous inspection.

Responsive – good.

Well-led - not inspected, rating of good carried forward from previous inspection.

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

Why we carried out this assessment.

We carried out a targeted assessment of the responsive key question. Targeted assessments enable us to focus on certain key questions to explore particular aspects of care.

How we carried out the assessment

• This assessment was carried out without a site visit.

• we conducted staff interviews using video conferencing.

• We requested evidence from the provider and reviewed the appointment system.

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:

  • Patient satisfaction with access had improved since the previous inspection in November 2022.
  • The provider had systems in place to monitor access and patient satisfaction. When it was identified that improvements were needed, the provider took appropriate action to improve the quality of services being delivered.
  • The provider worked with other organisations to provide services that met the needs of their patient population.

Whilst we found no breaches of regulations, the provider should:

  • Continue to monitor patient satisfaction and experience and take appropriate action when patient feedback identifies areas for improvement.

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 Health Care

15 November 2022

During a routine inspection

We carried out an unannounced comprehensive inspection at The Slieve Surgery on 15 November 2022. Overall, the practice is rated as good.

Safe - good.

Effective – good.

Caring - good.

Responsive - good.

Well-led - good.

Following the previous inspection on 22 September 2021, the practice was rated requires improvement overall and for safe and well-led key questions but rated good for providing effective services.

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

Why we carried out this inspection

We carried out this comprehensive inspection to follow up breaches of regulation from the previous inspection and to follow up on concerns reported to us about the way the practice was led and managed.

This was a comprehensive inspection and included:

  • The safe, effective, caring, responsive and well-led key questions.
  • We followed up any breaches of regulations and ‘shoulds’ identified in the previous inspection.

How we carried out the inspection

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

We found that:

  • The provider had taken appropriate action following the previous inspection to improve safety and governance systems and processes to become compliant with regulations.
  • 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-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Improve systems to review asthma patients following treatment for an acute exacerbation of asthma.
  • Continue to take action to improve uptake with children's immunisations and cervical cancer screening, to meet minimum targets.

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

22 September 2021

During an inspection looking at part of the service

We carried out an unannounced focused inspection at The Slieve Surgery on 22 September 2021 in response to concerns received. The practice was registered under a new provider, Dr Imran Zaman, in March 2021.

The practice had previous been rated good at an inspection on 26 October 2016 under the previous provider, The Slieve Surgery.

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.

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 and provider 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 site visit.

We have rated this practice as Requires improvement overall and good for all population groups except the population groups Families, children and young people and People whose circumstances make them vulnerable which are rated as Requires improvement.

We found that:

  • The provider was not able to evidence that recruitment checks were routinely being carried out before staff commenced employment.
  • Infection prevention and control was not managed effectively and areas from the practice’s audit had not been carried out. Following our inspection, the provider reviewed this.
  • The practice did not operate an effective system to routinely ensure safe monitoring of patients prescribed high risk medicines as well as patients on other repeat prescriptions.
  • A local care home had experienced delays in referrals for residents and was no longer using the practice.
  • Governance processes were not always effective, such as those to monitor recruitment processes, oversight of medicines management and the quality of medical records.
  • The provider did not demonstrate how they ensured transportation and storage of confidential health records were carried out in line with Data Protection Act 2018.
  • Staff did not always feel supported and improvement was needed in the practice’s culture.

The areas where the provider MUST make improvements are:

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

In addition, the provider should:

  • Improve the rates for child immunisations
  • Improve the rates for cervical screening

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