Archived: Dr Abdul Naeem Also known as Dog Kennel Lane Surgery

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 looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of legal regulation in relation to:

• Patients with long term conditions were not being reviewed regularly to ensure they received the appropriate care and treatment.

We found that the management of patients with long term conditions needed improving, patients’ needs were not always assessed and care and treatment was not always delivered in line with current legislation and evidence-based guidelines. We also found there was limited clinical oversight and a lack of supervision.

Patients received care and treatment that supported them to live healthier lives including being supported to undertake national screening programmes and vaccinations. The majority of patients who required monitoring underwent regular checks on their health.

Multi-disciplinary meetings were held where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

During the remote clinical review, we found patients with long term conditions were not being assessed appropriately. We carried out a clinical search to identify people who had been diagnosed with asthma who had been prescribed 2 or more courses of steroids in the past 12 months. The search identified 7 people. We reviewed a random sample of 3 records and found assessments of each patient had not been completed appropriately with limited evidence of a review having taken place. Further review of the records showed none of the patients had been followed up following an exacerbation of asthma as recommended by clinical guidelines to check patient’s response to treatment. None of the patients had been issued a steroid card. A steroid card provides information on how to minimise the risks when taking steroids.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We spoke with staff who were able to describe the process for coding of correspondence and care and treatment records for people. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them

We carried out a remote clinical review to identify the number of patients with diabetes that had a HbA1c over 75 recorded from the latest blood tests. A HbA1c blood test shows the average level of blood glucose. The search identified 39 people. We reviewed a random sample of 3 records and found all 3 patients were overdue a diabetic review and medication review with 2 out of the 3 patients not having been reviewed since 2022. Medicine alerts on the clinical records we viewed highlighted reviews were required, however we found no action had been taken.

We were unable to gain assurances that systems were in place to ensure staff were up to date with evidence-based guidance and legislation. We found clinical guidelines had not been followed in a range of long term condition monitoring. For example, asthma and diabetes.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral. We found the locum pack needed updating to reflect the current staffing levels. For example, the pack stated a health care assistant (HCA) was available, however there was no HCA working at the practice. Also, the information in the pack informed locums of access to a practice nurse on a Monday. There was no practice nurse available on this day.

Regular multi-disciplinary meetings were held, however the practice told us that they struggled to get community teams to join the meeting. They were able to contact community teams to share information when required to ensure care was co-ordinated effectively.

The Primary Care Network (PCN) helped to support the practice by providing links to pharmacists, dieticians, mental health practitioners and social prescribers. People were able to receive co-ordinated care between the practice and the primary care network.

Systems were in place to share information about patients electronically with other services. We were told informal clinical meetings were held monthly; however, these were not documented. Practice meetings were held every 3 months to ensure all staff were kept up to date with guidance and best practice.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

There were flags on patients records who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We identified some people with long term conditions had not received the appropriate monitoring and clinical guidance had not been followed. The practice had the support of a clinical pharmacist from the PCN and 2 part time locum nurses who each worked half a day a week.

The provider was performing below the national average for cervical screening targets. On speaking with staff, we were told more nursing time was required as there was limited availability of nursing appointments, however at the time of the assessment we found there were no plans in place to recruit more nurses or increase nursing hours. The practice had processes in place to recall patients. The practice had met the national targets for immunisations.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. We found that the practice had coded Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) on people’s clinical records where appropriate. However, on reviewing a random sample of 3 records we found no evidence to demonstrate that a DNACPR record had been completed.

We identified gaps in staff training on mental capacity; however, they understood legislation when considering consent and decision making.

We saw evidence that consent was obtained for patients so that they understand their rights around consent to the care and treatment they are offered. The national GP patient survey demonstrated that 95% of patients were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was higher than the national average of 91%.