All inspections: The Balaji Surgery - Care Quality Commission

We carried out a review of the data available to us about The Balaji Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Balaji Surgery, you can give feedback on this service.

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 www.cqc.org.uk

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

We carried out an announced comprehensive inspection at Balaji Surgery on 21 May 2019 as part of our inspection programme.

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 Requires Improvement overall and requires improvement for all population groups.

We rated the practice as requires improvement for providing safe, caring, responsive and well led services because:

The practice had a system for recording incidents and significant events, however we found the significant event policy needed reviewing to ensure it covered all possible risks and learning from incidents needed strengthening with the whole team to ensure risks were mitigated.
On reviewing the safeguarding register we found parents of children identified as at risk had not been linked through the medical records to ensure safeguarding concerns were monitored effectively.
The system for the management of safety alerts was not effective in ensuring all alerts had been received and acted on.
The leadership team had a strategy to respond to the challenges they had identified, however we found the practice were unable to demonstrate sustainability had been considered effectively with the reduction of clinical staff time.
Patient satisfaction results were below local and national averages for access. The practice had implemented an action plan, but had not gathered patients views on how the plan had improved access.
The practice had not completed their own internal survey to gather patient feedback.

The areas where the provider must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Review current processes for learning from incidents and events to ensure risks are mitigated.
Review the current processes for monitoring of staff training to identify gaps in staff updates relevant to their role.
Review systems for the monitoring of safety alerts to ensure all alerts relevant to the practice have been received and acted on.
Update the safeguarding register with the relevant links to ensure patients with safeguarding concerns are monitored effectively.
Monitor patient feedback to ensure changes implemented are improving patient satisfaction.

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

The Balaji Surgery

All Inspections

6 July 2023

During a monthly review of our data

17 June 2021

During an inspection looking at part of the service

During a routine inspection