Dr Azim Khan Also known as Unity Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This service scored 71 (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 had a very clear shared vision, strategy and culture.

The practice was led by the principal GP, who was supported by a salaried GP, locum GP, practice manager, assistant practice manager and the administration team. They were supported by healthcare professionals employed through their primary care network (PCN) such as a clinical pharmacist.

Whilst they were a small practice, a strategy was in place to ensure future proofing and continuity which included taking on a partner and increasing clinic rooms to accommodate more clinicians. Staff told us the team felt stable since the employment of new staff, including the practice manager. The size of the team enabled ease of communication and decision making. Staff spoke very positively about the manager and told us they felt confident in their leadership.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. This included increasing the building’s capacity to have more clinic rooms through an extension.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty. Staff told us leaders in the practice were approachable and responded to any concerns raised. They told us they could approach all clinicians and the management team without fear of retribution.

We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There were systems in place to support staff to whistle blow or to speak with a Freedom to Speak Up Guardian if they had any concerns. Staff were aware of how to whistle blow and who the Freedom to Speak Up Guardian was and what their role was in supporting staff. The practice had established Freedom to Speak up arrangements with the Integrated Care Board.

However, no staff had felt the need to contact them as they felt they could speak with the management team in place or any partners if they had any concerns.

We spoke with 6 staff who told us they felt there was a positive culture within the team and all felt supported by the leadership team.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At our previous inspection, we found governance processes required improvement because they were not effective in all areas. At this assessment, we found these had improved and the provider was no longer in breach of regulations.

The service had clear responsibilities, roles, systems of accountability and good governance. Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. The practice had a clear and strong clinical and governance management structure in place.

Managers met with staff regularly to complete appraisals and performance reviews. Every staff member had an annual appraisal in place that was development focussed. All staff we spoke with told us they always had the opportunity to develop if they chose to.

Governance processes were in place for sharing safeguarding information with partners including the local authority and other community teams.

Staff could access all required policies and procedures. All practice policies and procedures were available on the practices shared drive, which all staff had access to.

Managers held regular practice meetings with staff, both formal and informal, during which they discussed clinical concerns and emerging risks. The practice had a regular protected learning time in place.

Staff took patient confidentiality and information security seriously. All staff had appropriate information security training in place.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborate for improvement.

Leaders described positive working relationships with other practices within their primary care network (PCN). The PCN employed staff in additional roles such as first contact physiotherapists and pharmacists who worked across the network, thereby improving consistency in the delivery of services within the group of the practices.

There were processes in place to work in partnership with key organisations and agencies to support the provision of care and joined up working. Staff told us they regularly went over and above for people by referring them to services within the community such as the local health and wellbeing service to support them to live healthier lives.

The practice had an active PPG who told us they were involved in campaigns and had recently undertaken projects including promoting the use of the NHS App. The lead GP always attended PPG meetings to provide updates on any changes occurring within the practice.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. The integrated care board (ICB) informed CQC the practice was engaged with the ICB and the primary care network. Leaders attended regular operations meetings with their primary care network where they shared initiatives, referral processes and learning.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They provided postgraduate training to qualified doctors, with further training capacity planned in the near future. Trainees were actively involved in quality improvement audits and worked collaboratively with other clinicians aligned to the practice, for example, pharmacists, to promote wider learning.

GPs at the practice were early adopters of an artificial intelligence tool to save time on documentation by using the tool to transcribe during consultations. They found it increased accuracy of recording, was more reflective and enabled easier production of referral letters.