You are here

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 10 August 2021

For providing

We carried out an announced inspection at The Balaji Surgery on 17 July 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective – Requires improvement

Caring - Good

Responsive – Good

Well-led - Good

Following our previous inspection in May 2019, the practice was rated Requires Improvement for safe, caring, responsive and well-led and rated requires improvement overall. The service was rated good for effective.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Balaji Surgery on our website at

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to follow up on:

  • Safe, effective, responsive, caring and well-led key questions.

  • The breaches previously identified at our inspection in May 2019

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 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 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 rated this practice as good for providing safe, caring, responsive and well-led services and good overall. For providing effective services we have rated the practice as requires improvement. We have rated the population groups people with long term conditions, families, children and young people and working age people (including those recently retired and students) as requires improvement. All other population groups were rated good.

We found that:

  • The practice had improved systems and processes to provide care in a way that kept patients safe and protected them from avoidable harm. However, further improvements were required to ensure strong processes to protect vulnerable children.
  • Patients received effective care and treatment that met their needs, although some areas needed further improvement including uptake rates for cervical cytology, childhood immunisation and some areas of long term conditions management.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. The practice had increased appointments to improve access to care. Whilst this had yet to impact fully on the national GP patient survey, we saw that there were some improvements.
  • The leadership and management team were aware of the challenges and areas for improvement and had implemented actions to promote the delivery of high-quality, person-centre care.

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

  • Improve cervical cytology and childhood immunisation uptake.
  • Where patients are managed by secondary care, implement appropriate documentation to evidence that up to date blood test results were checked before prescribing medicine.
  • Develop effective processes to ensure children under safeguarding concerns are linked appropriately so that staff are aware of potential risks.
  • Improve Personalised Care Adjustment (PCA) rates for patients with dementia so that they are within local and national averages.
  • Improve process for effective management of patients with diabetes.
  • Document reviews of competency undertaken with the healthcare assistant (HCA) undertaking dementia and asthma checks.

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




Requires improvement






Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable