Archived: Dr Aamer Khan Also known as The Lister Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There were processes in place to record, investigate, take action and learn from incidents and complaints. There were designated safeguarding leads and appropriate safeguarding processes in place. Staff understood the importance of keeping people safe, and how to escalate any safety concerns. The premises and equipment were clean and tidy. There were some clinical supervision processes in place, however these were not always documented, and did not include the undertaking of prescribing audits for non-medical prescribers. There were some concerns around the monitoring of patients and with the actioning of safety alerts, however the practice took action to address these concerns.

This key question has been rated as Good.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were policies and processes in place to record, investigate and act on incidents and complaints. These were discussed in clinical meetings, and minutes were made available to staff. Lessons were learnt to continually identify and embed good practice. For example, an incident whereby a patient was given an incorrect dose of a medicine resulted in the practice seeking advice from a specialist, informing the patient, and discussing this in a practice multidisciplinary meeting. Staff told us they were confident to raise concerns when things went wrong, and that they felt appropriate action was taken to protect staff and patients.

There were policies in place to support the workflow and pathways for appointments, referrals and correspondence. There were processes to monitor and manage care when patients moved between services, such as out of hours or after referral to secondary care. Measures were in place to monitor and audit referrals, particularly those related to cancer 2-week waits. Staff we spoke with understood the referrals and pathology results processes, as well as how to safely manage medical correspondence. A review of the practice clinical system, which formed part of this assessment, indicated that patient test results were being managed in a timely manner. There was however a backlog of 874 patient records to be summarised, with the practice manager being the only trained summariser. The practice told us there were plans in place to train 2 more members of staff in summarising, to work through this backlog. In order to mitigate risk, the practice requested medical histories from patients at registration, and offered health checks for new patients.

There were designated safeguarding children and adult leads at the practice. Safeguarding policies contained relevant contact details and processes to follow. There were also specific policies for children not brought to appointments. Staff were appropriately trained in safeguarding, and those carrying out chaperoning had received specific training for this process. Staff told us how they used the clinical system to record and alert others to safeguarding concerns, and explained how they escalated any concerns. There were monthly multidisciplinary meetings where safeguarding cases were discussed, and these were attended by practice staff and often by external staff such as district nurses and members of the proactive care team.

There were processes in place for managing emergencies. Staff we spoke with knew where to locate emergency drugs and equipment. We saw that checks on emergency drugs and equipment were carried out and recorded regularly. Staff received training in sepsis awareness and basic life support, and were able to explain how to act safely in an emergency, including alerting clinical staff and emergency services.

There were processes in place for health and safety risk management. For example, risk assessments had been undertaken, and fire alarm testing and evacuation drills were carried out on a regular basis. It was however noted that designated fire marshals were overdue training for this role. The practice manager told us there were plans for this training to be completed in October 2025. There was appropriate signage in place, such as for fire doors and escape routes. We saw that equipment was maintained, stored safely and was suitable for use. Electrical equipment had been tested, and clinical equipment had been calibrated to ensure correct operation. Staff we spoke with told us that they had no concerns related to health and safety in the practice.

There were policies in place for recruitment and appraisal. Staff received regular appraisals, and induction packs were provided to new staff. We reviewed 3 staff personnel files as part of this assessment and found that documentation was generally in line with guidance. We saw Disclosure and Barring Service (DBS) checks, immunisation records and appraisal records were kept. However, some documentation which was noted by the practice to have been checked at the recruitment stage, could not be found in file. After the assessment the practice told us it had placed any missing documents into the staff file and would monitor this process going forward.[MK1]

Leaders told us about the ways in which they ensured staff were qualified and skilled to carry out their roles, and the support that they offered them. For clinical staff, this included supervision and case discussions, however this was on an ad-hoc basis and not documented, and did not include audits of prescribing for non-medical prescribers. During the assessment the practice produced a clinical supervision policy which detailed plans for formal and regular documented sessions of clinical supervision going forward.

The practice requested immunisation histories for clinical staff only. After the assessment the practice told us it was in the process of obtaining this information from non-clinical staff and would refer staff to the practice’s occupational health service where required.

Staff had access to appropriate training to meet their learning needs and to cover the scope of their work. There were systems to monitor when mandatory training updates were due. At the time of the assessment staff were generally up to date with required training.

Staff told us they had enough support to carry out their role and would not hesitate to seek further guidance from senior staff when needed.

There was an infection prevention and control (IPC) policy in place. Staff received IPC training and those who handled clinical specimens explained how they did this safely.

Staff knew who the IPC lead was and how to raise IPC concerns. There were yearly internal and external IPC audits, and 6-monthly hand washing audits.

We found the practice premises and equipment to be clean and tidy. Appropriate personal protective equipment was available to staff. Clinical waste was appropriately managed by an external company.

Medicines were stored securely and at appropriate temperatures. Refrigerators used to store vaccines and medicines were regularly cleaned, temperatures were monitored and logged, and products were appropriately stored within them. Staff regularly checked stock levels and expiry dates for medicines.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this as the practice performance was in line with or better than national averages for all indicators. For example, data from April 2024 to March 2025 showed that the percentage of Co-amoxiclav, Cephalosporins and Quinolones prescribed was at 5.3%, which was better than the national average of 7.8%. Clinical audits of prescribing were also carried out which focused on improving care and treatment. In addition, the practice had recently produced a plan for reducing antibiotic prescribing within the practice; this included an audit of antibiotics prescribed per session per clinician.

There were Patient Group Directions and Patient Specific Directions in place which relevant staff worked to.

As part of our assessment a Care Quality Commission GP specialist advisor undertook searches of patient records on the practice’s clinical system. Overall, our searches showed that medicines were not always effectively managed by the practice. However, where issues were identified, the practice was proactive in addressing these. We found the following:

Methotrexate (a disease-modifying anti-rheumatic drug): We identified 4 patients and found that 1 had not received the required monitoring in the last 6 months. We looked at all 4 patient records in detail and found that there was sometimes no documented link to the condition for which the patients were taking the medication (to clearly indicate what the medication was being prescribed for). In addition, all 4 records did not specify the day of the week the medication was to be taken, in line with Medicines and Healthcare products Regulatory Agency (MHRA) guidance. After the assessment the practice told us it had linked conditions to the medication, and would ensure the day of the week was recorded going forward.

Aldosterone antagonists (potassium sparing diuretic): We identified 13 patients with heart failure who were prescribed this medication. Of these, 2 had not had the required monitoring. We looked at these 2 records in detail and found that patients had either been out of the country or had not attended scheduled appointments.

Pregabalin (teratogenic drug, which refers to a drug that can cause birth defects): We identified 8 patients who were prescribed this medication. We reviewed 3 records in detail and found that patients were not always advised of risks in a timely manner. After the assessment the practice told us it had raised this issue as a learning event and shared it with all clinicians within the practice to ensure timely dissemination and action of safety alerts in the future.

Potential missed diagnosis of diabetes: We identified 10 patients. We found that of these, some had not attended scheduled appointments. The practice also told us that some records could not have been coded any earlier as repeat blood testing had only recently been carried out (as appropriate). After the assessment the practice told us it had reviewed all 10 records and would take any further required action where necessary.

There had been 248 medication reviews carried out in the last 3 months. We reviewed a sample of these and found that some were thorough and detailed whilst others contained limited information. After the assessment the practice told us it would raise this with staff as appropriate.