Dr Azim and Partners

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed all quality statements for this key question and rated the practice as good for providing effective services. We found there had been improvements made to how care was delivered at the practice following the inspections in November 2022 and at the follow up inspection in May 2023, particularly in relation to the treatment of long-term conditions. At our last comprehensive inspection in November 2022, we rated this key question as inadequate.

We found care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved. Staff were passionate about supporting patients to live healthier lives. We found the practice should make improvements where patient care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance, and where patient needs were not always assessed in a timely manner.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient feedback gathered in the 2024 National GP Patient Survey (GPPS) indicated that 78% of patients felt their needs were met during their last general practice appointment. This was lower than the local average GP practice score of 88% and lower than the national average GP practice score of 90%. A total of 123 surveys were completed by patients which was a completion rate of 21%.

During our assessment, a CQC specialist advisor reviewed patient records to check the management of patients with long-term conditions at the practice. These searches undertaken were visible to the practice. One search we looked at related to the pre-diabetes checks. We conducted a search for patients with the possible diagnosis of diabetes following a blood test result and identified 1 patient with a potential missed diagnosis of diabetes. The patient had 2 occasions where were was a long interval between testing. We discussed this with the GP partners and they told us the patient had been with a different practice at the time. The practice told us it conducted bi-annual searches of diabetes patients and that it was due to conduct a search in September 2024.

At our follow up inspection on 4 May 2023, we identified there were issues in relation to the management of patients with acute exacerbation of asthma. At this inspection, we reviewed patients with acute exacerbation of asthma who were prescribed 2 or more courses of rescue steroids in the last 12 months and found patients were appropriately monitored. Patients we reviewed with CKD stages 4 or 5 were monitored appropriated. We reviewed patients with hypothyroidism who had not had thyroid function test monitoring for 18 months and found there were 2 patients. We discussed these patients with the practice. 1 patient had overdue blood testing and this had recently been requested by the practice. The other patient had failed to attend appointments and their prescription had been stopped. We found no issues with the management of patients with diabetes with HbA1c over 74 mmol/l. The practice reiterated that when patients did not engage in monitoring, prescriptions would be reduced and eventually stopped if the lack of engagement persisted.

During our clinical searches, we observed medication reviews had not always been completed in detail, with a code listed but no discussion detailed. The practice told us searches had sometimes identified patients needing medication reviews but they had no routine medicines prescribed. In these circumstances, the practice had coded a medication review but had not added any comments. The practice assured us it would review this process.

The practice told us it followed protocols and National Institute for Health and Care Excellence (NICE) guidelines to ensure safe care and treatment was delivered. The practice discussed guidance and changes in guidance at clinical and practice meetings and during appraisals with staff members. The practice told us all guidance was available for staff to view on Teams. However, we found the surgery did not always plan and deliver people’s care and treatment using evidence-based care and treatment. We found some systems were inadequate to ensure effective monitoring of patients’ care and treatment. We saw evidence of this in the way the surgery monitored patients prescribed some high-risk medicines, including Lithium and Benzodiazepines and Z-drugs and medication reviews.

The service told us clinical staff regularly liaised with other health professionals and attended meetings to review patients with complex or safeguarding needs. The practice told us it held regular meetings with a variety of healthcare professionals and facilitated referrals of patients to other services within the community. The practice ensured patients who were discharged from hospital after being acutely unwell were followed up appropriately and where required would see these patients within 24 to 48 hours post discharge.

The practice supported a care home and arranged multidisciplinary team meetings to discuss patients’ needs with the district nurses and palliative care team where required. We received feedback following this inspection that communication between the practice and the care home was not always working well, with concerns raised about this practice’s responsiveness, delays in processing referrals and ensuring timely care for residents. The practice informed us that it had worked with the care home during a change in provider and had established communication and held meetings with the care home during the transition period to ensure continuity and a smooth handover of care. The practice had completed an audit on referrals which indicated that 90% of referrals were sent within one working day.

The practice encouraged and supported patients to live healthier lives. Staff members we spoke with told us patients could, with their consent, be referred to a mental health practitioner, wellbeing coach and social prescriber. The practice informed patients of services available through the Primary Care Network (PCN) including food banks, exercise classes and yoga classes and provided patients with leaflets about these services. The practice liaised with the PCN (one of the GP partners was a director of the PCN) and were looking at establishing a joint pain clinic. The practice was able to refer patients to a PCN dietician and told us a patient with diabetes could generally be seen within 1 week by a dietician. The practice told us it had good contacts with local practices and the practice manager met with local practice managers and shared ideas. The practice gave us an example of identifying patients who were homeless and discussed referrals to other services for these patients. The practice also told us about signposting patients to community pharmacies for contraceptive advice where they declined to visit a GP. The practice website had information within the patient news section on self care events.

The practice told us the GP partners had oversight of long-term conditions and a care navigator was responsible for conducting searches for patients on the practice system and making arrangements for appointments. We saw some areas of good practice, for example, we found the practice effectively monitored patients with acute exacerbation of asthma. The practice told us the asthma nurse was a prescriber and a patient with acute exacerbation of asthma would be booked in to see the nurse when a hospital letter was received or if a GP saw this patient. Patients were normally seen within 24 to 48 hours and would be followed up if they did not attend. We saw evidence patients with long-term conditions were discussed at clinical meetings. The practice told us it conducted bi-annual searches for diabetes patients and that it was due to conduct a search in September 2024.

We asked the practice what work had been done regarding quality improvement. The practice told us it had focused on auditing the prescribing of antibiotics and we saw evidence of a two-cycle audit. The first cycle, reviewing a sample of consultations between September and November 2023 was discussed at a clinical meeting and an action plan was put in place to improve compliance. The second cycle, reviewing a sample of consultations between March and May 2024 showed an improvement in prescribing in accordance with NICE guidelines. The audit was discussed at a clinical meeting and a further action plan was set to improve compliance.

The practice had a rate of 57.3% for the uptake of cervical cancer screening, which was below the expected uptake rate of 80%. The practice told us it was working towards improving and reducing the barriers to uptake. We saw evidence the practice had completed an action plan to address uptake which included ensuring staff were trained to discuss the importance of cervical screening with patients, offering flexible appointment times including evenings and weekends to accommodate working people, sending patient invitations and reminder invitations, and a need to consider specific needs with patients, cultural and language barriers, and physical limitations and disabilities. The practice invited all patients to book appointments during a cervical cancer awareness week in 2024. Patients were sent a self-book link to book an appointment. The practice blocked time out for the nurse to provide a walk-in service for patients, including for patients who wanted to speak with a nurse with questions about cervical screening. The practice offered longer appointments for patients who had questions or concerns about cervical screening due to religious and cultural reasons. The practice had information about cervical screening available for patients at the surgery and information on its website. The practice had an appropriate process for the checking of results, chasing results not received and a failsafe process.

The practice had not met the expected minimum 90% uptake for all of the childhood immunisation uptake indications and had not met the World Health Organisation (WHO) based national target of 95% (the recommended standard for achieving herd immunity) for all of the childhood immunisation uptake indicators. The practice told us that it was working towards improving and reducing the barriers to uptake. We saw evidence the practice had completed an action plan to address the uptake of immunisations and reduce barriers to uptake. This included the aim of increasing uptake by 15% over 2 months, identifying and contacting patients not vaccinated or overdue for vaccinations, establishing a recall system to notify parents and guardians of immunisations due, monitoring and reporting on uptake rates monthly, collaboration between healthcare professions and administrative staff to streamline the process and providing training to staff members. The practice sent out an invite to relevant patients which allowed them to self-book an appointment. The practice nurse allocated time to speak with patients who were concerned about the immunisation process. The practice nurse liaised with local GP nurses and was part of a forum where ideas were shared to improve uptake.

The practice told people about their rights around consent and these rights were respected when person-centred care and treatment were given to patients. Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented appropriately. The practice completed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in line with relevant legislation. We reviewed the DNACPR decisions of 5 patients and found that decisions were made in line with relevant legislation with appropriate consent obtained.