Dr Azim and Partners

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed all quality statements for this key question and rated the practice good for providing well-led services. We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open and fair culture. At our last comprehensive inspection in November 2022, we rated this key question as inadequate. At this inspection, we found the surgery had improved governance in most areas, however, we found areas for improvement. These included improving systems and processes for the monitoring and prescribing of some high-risk medicines, completion of detailed medication reviews and ensuring equity in access. The risk in relation to low attainment scores achieved by the national GP patient survey had not been analysed and addressed at the time of our inspection.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a mission statement which included that its vision was to work in partnership with the wider community and provide excellent healthcare to improve the health and wellbeing of the local population. The mission statement stated this vision would be achieved through teamwork, inclusivity, respect and dignity, caring, a commitment to high quality care and by making a difference. Staff members we spoke with were fully conversant with the practice’s mission and values and evidenced their understanding and role in achieving this. Leaders told us that there was an open and inclusive culture at the practice, and this was confirmed by staff members we spoke with. Staff told us how they understood the importance of meeting the needs of the patient population and to review care when needs changed.

The practice encouraged learning and development of staff members and we saw several examples of where the practice had supported staff in their career aspirations. The practice promoted wellbeing and used an external HR service which offered counselling sessions. The practice had an employee of the month award to recognise contribution and held a mental health awareness week. GP partners arranged extra-curricular activities for staff. The practice conducted an anonymous staff survey where staff members could raise concerns and was due to discuss results in August 2024. Staff members were able to raise concerns in person at practice meetings and told us that they felt comfortable to do so. Leaders told us that it had encouraged innovation and ownership and that staff had directly contributed to a reconfiguration of the processing of information at the practice with the implementation of a pigeon-hole system. The improvements ensuring that staff could find documents in a timely manner, which led to a reduction in complaints.

The practice had inclusive leaders who were supportive of their staff to deliver patient care that was compassionate and showed the ethos of the practice. We received feedback in staff interviews that suggested there was a positive relationship between staff, management and clinical staff, with staff reporting that they felt supported and enjoyed working at the practice. Staff members told us they felt comfortable and confident in raising any concerns with leaders. The practice told us it did not currently have any succession plans, but would review this in the future where necessary. The practice told us it had identified the challenge of recruitment and retention of the workforce and that it had recently recruited clinical staff to meet capacity and demand. The practice promoted education and training for staff members. The practice told us it had good contacts with local practices and attended PCN meetings on a regular basis. A GP partner was a director of the PCN and was involved in promoting several of the PCN projects, for example, exercise classes, pain clinic and use of dieticians. The practice manager regularly attended a meeting of local practice managers where ideas for improvement could be shared.

Staff members we spoke with at the practice told us management fostered a culture where people felt they could speak up and that their voice would be heard. The practice told us new staff members would be made aware of the whistleblowing policy during the induction process and it was available for staff to refer to electronically on Teams. Staff members we spoke with told us they were comfortable in making their views heard and there were opportunities to so do in staff meetings, privately with managers, in appraisals and in the anonymous staff survey.

The practice valued diversity in its workforce. Staff members were required to complete training on equality and diversity. The practice had a diverse workforce from different cultures and backgrounds and the practice promoted respecting each other and had received external training on compassion. The practice had policies and procedures in place to promote workforce equality, diversity and inclusion. Staff members had access to continual professional development and mentorship.

The practice did not always have clear systems of accountability and good governance. Although the practice had assurance and governance policies in place, this assessment found improvements in systems and processes were required for the monitoring and prescribing of some high-risk medicines, completion of detailed medication reviews and equity in access. Whilst the practice had previously analysed the results of the GP patient survey, at the time of assessment it had not reviewed the results of the most recent published survey and therefore had not devised an action plan to address poor feedback. The practice results fell below, sometimes well below, the local GP average and national average scores. However, the practice had attempted to access patient feedback using a variety of methods including conducting its own survey and analysing results, analysis of Friends and Family feedback, promoting how to make complaints on its website and in the surgery and conducting an annual complaints review to identify themes where improvements could be made.

The practice collaborated with other healthcare professionals in partnership to provide care for the patient population and shared information to promote learning and improvement. The practice continued to promote continuous improvement by acting on complaints and feedback received, and we saw evidence of changes made to the telephone system as a direct result of feedback. The practice had struggled to form a new patient participation group (PPG) after holding a meeting for patients to discuss the aims and objectives of the group and was looking into the possibility of using patient champions at the practice as an alternative to the PPG. The practice was actively involved with the PCN and interacted with other practices in the locality. The practice held multidisciplinary meetings to discuss and improve outcomes of patients with complex needs. The practice collaborated with stakeholders and held meetings engaging with district nursing and palliative care teams. Leaders collaborated with the PCN at monthly meetings and shared information. We received some feedback regarding the service the practice provided to a local care home where concerns were raised about communication, the practice’s responsiveness, delays in processing referrals and ensuring timely care.

Staff members told us leaders supported them in their development and encouraged them to take up learning opportunities. Staff were given allocated time to complete mandatory training, were offered additional training to suit their career aspirations and were encouraged to suggest improvement ideas. There was evidence of systems and processes for learning, continuous improvement and innovation. Significant events and complaints were used for learning and improvement.