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Dr Abdul-Kader Vania Inadequate Also known as Ar-Razi Medical Centre

Inspection Summary


Overall summary & rating

Inadequate

Updated 4 August 2021

We carried out an announced focused inspection at Dr Abdul-Kader Vania on 15 July 2021 to review compliance with four warning notices issued following our previous inspection on 22 April 2021.

In April 2021, the practice was rated as inadequate overall and also for the key questions of safe, effective and well-led. The practice was placed into special measures. This inspection on 15 July 2021 was undertaken to review compliance with the warning notices which had to be met by 30 June 2021, but the inspection was not rated. The ratings from April 2021 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 Abdul-Kader Vania on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a focused inspection to follow up on:

  • Compliance with warning notices issued in respect of breaches of regulation 12 (safe care and treatment); regulation 13 (safeguarding service users from abuse and improper treatment); regulation 17 (good governance); and regulation 18 (staffing).
  • A review of the standards of record-keeping associated with the private circumcision service provided on site.

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 interviews using video conferencing.
  • Undertaking remote access to the practice’s patient records system to identify issues and clarify actions taken by the provider and to discuss findings. This was in relation to safeguarding and circumcision patient records only.
  • Requesting evidence from the provider to be submitted electronically.
  • A short 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 have not rated this practice as the rating remains unchanged until we have completed a further inspection incorporating all relevant key questions.

However, we found that:

  • Action had been taken to address the breaches identified in the warning notices and it was evident that improvements had been made. However, we found that some required actions were ongoing and were not yet fully completed or embedded. These related to the warning notices for regulation 13 (safeguarding service users from abuse and improper treatment) and regulation 17 (good governance). As a result, the areas where the provider must make improvements are:

  • Ensure patients are protected from abuse and improper treatment.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We were satisfied that sufficient work had been completed to demonstrate compliance with the warning notices issued in respect of regulation 12 (safe care and treatment) and regulation 18 (staffing).

We also found that patient records for circumcisions were predominantly maintained in accordance with good record keeping guidance.

In addition, the provider should:

  • Continue to deliver the action plan supported by evidence, which should be reviewed and updated on an ongoing basis.
  • Further develop the inclusive and structured approach to improvement with the practice team and promote specialist input from local leads, for example the CCG’s safeguarding lead GP and infection control team
  • Improve staff awareness of key responsibilities, for example, safeguarding, dealing with complaints, and infection control.
  • Improve the uptake of cervical screening and childhood immunisations, building on the improvements made since our previous inspection.
  • Develop the evidence base for all employed staff and locums with regards their immunisations status in line with national guidance.

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

Inspection areas

Safe

Inadequate

Effective

Inadequate

Caring

Good

Responsive

Good

Well-led

Inadequate
Checks on specific services

People with long term conditions

Inadequate

Families, children and young people

Inadequate

Older people

Requires improvement

Working age people (including those recently retired and students)

Inadequate

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement