The Care Quality Commission
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  • GP practice

The Avicenna Medical Practice

Overall: Good read more about inspection ratings

Barkerend Health Centre, Barkerend Road, Bradford, West Yorkshire, BD3 8QH (01274) 664464

Provided and run by:
The Avicenna Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Avicenna Medical Practice 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 Avicenna Medical Practice, you can give feedback on this service.

21 April 2022

During a routine inspection

We carried out an announced inspection at The Avicenna Medical Practice on 20 and 21 April 2022. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 18 July 2019, the practice was rated good overall and for all key questions but requires improvement for the care provided to working age people. During inspections the CQC no longer reports on the care afforded to different population groups individually but includes this information within the Effective key question.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Avicenna Medical Practice on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a comprehensive inspection undertaken at the same time as the CQC inspected a range of urgent and emergency care services in West Yorkshire. We undertook this inspection to review the quality of care delivered by GP providers and the experience of people who use GP services. We asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system-wide feedback. We also included additional questions to establish the practice response to access to appointments for patients following the COVID-19 pandemic.

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 telephone and 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
  • Staff questionnaires

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 overall.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The uptake of bowel, breast and cervical cancer screening at the practice was below national averages. However, we saw that ongoing actions were being taken to improve uptake and attendance, and to enhance the understanding of the need for cancer screening. The team continually encouraged, monitored and reviewed screening uptake.
  • End of life care was delivered in a proactive and coordinated way which took into account the needs of the person and their family. A named clinician was allocated to the family and staff had worked to gain additional competencies in managing end of life care. Care and support was delivered as necessary alongside members of the multidisciplinary team, and we saw timely and supportive referrals were made.
  • Staff dealt with patients with kindness and respect. We observed staff speaking to patients in the language of their choice and in a calm and friendly manner.
  • The practice adjusted how they delivered services to meet the needs of patients during the COVID-19 pandemic. Alongside telephone and video consultations, face to face appointments had been continually offered throughout the pandemic, following clinical triage. Patients could access reception services during opening hours. A practice survey undertaken in November 2021 found that 88% of patients confirmed they could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Clinical staff were described as consistently supportive and approachable. The practice manager was described by staff as a ‘supportive enabler’ who encouraged staff to succeed.
  • The practice developed the cultural competence of staff to address the needs of their diverse population. For example, ensuring timely completion of documentation following patient deaths to facilitate religious burial timeframes, offering additional support for immunisations and screening and seeking additional staff training to enable clinicians to competently assess and support high numbers of patients with complex needs such as diabetes and obesity.

We found an example of outstanding practice:

  • At this inspection we saw that the team embraced initiatives and every opportunity to work collaboratively with stakeholders, members of the multidisciplinary team and outside agencies to provide safe and effective joined-up care that prioritised patient needs and reduced inequalities. We saw evidence of timely referrals, regular communication, individualised holistic support and the continual audit and review of care, to ensure that patients received the highest possible quality of care. For example; the team had one of the highest referral rates within the Clinical Commissioning Group to the diabetes prevention programme and staff were allocated lead roles in promoting support to reduce inequalities within the practice population.

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

  • Encourage and improve uptake rates for childhood immunisations.
  • Encourage and improve uptake rates for cancer screening programmes.

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

18/07/2019

During a routine inspection

We carried out an announced comprehensive inspection at The Avicenna Medical Practice on 24 October 2018. The overall rating for the practice was inadequate. We carried out a further focused inspection, on 16 April 2019. This inspection was to review actions taken by the provider in response to the warning notices issued by the Care Quality Commission after the October inspection for breaches of Regulation 12 (Safe care and treatment) and Regulation 18 (Staffing). At the inspection on 16 April 2019, we found that the provider had responded to our concerns and was compliant with regulations 12 and 18.

This inspection carried out on 18 July 2019, was an announced comprehensive inspection of the service which also reviewed in detail the breach of Regulation 17 (Good governance) from October 2018.

We have rated this practice at this inspection as good overall.

We rated the population group of working age people as requires improvement because the number of patients accessing cancer screening services remains below national averages.

The report for the April 2019 inspection and previous inspection reports can be found by selecting the ‘all reports’ link for The Avicenna Medical Practice on our website at .

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • evidence provided to us by the practice

We found that:

  • The provider had reviewed and improved the system for the documentation, discussion, review and management of complaints and significant events.
  • The required training had been reviewed and completed in line with the practice policy. All staff had now completed child and adult safeguarding training
  • The practice had made significant efforts to communicate with their patients and respond to patient feedback. This included surveys and the documentation of verbal complaints and compliments which were reviewed with the team. Outcomes from the 2019 GP patient survey showed improvements in the patient experience.
  • Staff at the practice were supported by effective leadership, good communication channels and clear systems and processes.
  • A comprehensive audit programme had been developed and the practice was participating in audits both internally and externally. The practice responded to national safety alerts and reviewed patient care and treatment when necessary.

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

  • Improve the uptake of cancer screening at the practice including breast, bowel and cervical screening.
  • Improve outcomes for patients with diabetes.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

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

16/04/2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at The Avicenna Medical Practice on 24 October 2018. The overall rating for the practice was inadequate. The full comprehensive report on the October 2018 inspection can be found by selecting the ‘all reports’ link for The Avicenna Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection, carried out on 16 April 2019 to review actions taken by the provider in response to the warning notices issued by the Care Quality Commission after the October inspection. We issued warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 18 (Staffing).

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • evidence provided to us by the practice

We found that:

  • Patient Group Directions (PGDs) were now in place for staff who were not authorised by their profession to administer vaccines unless they are covered by a PGD.
  • The provider had reviewed and improved the system for the documentation, discussion, review and manage of significant events.
  • All staff had now completed child and adult safeguarding training.
  • Mandatory training had been reviewed and completed in line with the practice policy.

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

24/10/2018

During a routine inspection

We carried out an announced comprehensive inspection at The Avicenna Medical Practice on 24 October 2018 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a second CQC inspector and a GP specialist advisor. The practice was previously inspected on 18 November 2014 and was rated as good.

Our judgement of the quality of care at this service is based 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 inadequate overall.

We found that:

•People were not adequately protected from avoidable harm and abuse.

•The delivery of high quality care was not assured by the leadership, governance and culture of the practice.

•Some legal requirements were not met.

We rated the practice as inadequate for providing safe services because:

•The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse. We saw that numerous members of the clinical team including advanced practitioners and nursing staff had not attended any child safeguarding training. For those staff that that had completed safeguarding training, the provider could not evidence that they were trained to the required level. Several key staff members of staff had not attended adult safeguarding training.

•The provider did not have an effective system in place for the documentation, discussion, review and management of significant events. The provider could not evidence that reflections or learning from incidents or changes to policies or procedures were disseminated and discussed with staff team.

We rated the practice as inadequate for providing effective services because:

•There was limited monitoring of the outcomes of care and treatment.

•The provider was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.

•The provider did not carry out any quality improvement activity.

•There were significant gaps in staff mandatory training which did not align with policy requirements at the practice. A number of staff were not trained in equality and diversity, infection prevention and control, fire training, health and safety, sepsis and learning disability awareness.

We rated the practice as inadequate for providing caring services because:

•The practice did not respond in a meaningful way to patient feedback.

•National GP patient survey data showed that patient satisfaction in relation to feeling cared for were below CCG and national averages.

We rated the practice as inadequate for providing responsive services because:

•National GP patient survey data, 2018 showed that patients were not able to access services in a timely manner. Patients told us on the day of inspection that they experienced difficulty getting an appointment.

•The practice could not demonstrate they had responded to the National GP patient survey 2018 results, despite responses to the survey being significantly below national averages.

•The systems and processes for receiving and acting on complaints were not operating effectively. The practice did not document verbal complaints and therefore could not evidence that all complaints to the practice were documented and responded to appropriately. Complaints were not reviewed and discussed with the staff team. The practice could not demonstrate that complaints were responded to in accordance with the NHS complaints procedure or that changes were made as a result.

We rated the practice as inadequate for providing well-led services because:

•The overall governance arrangements were ineffective. Systems and processes were not established or operated effectively to ensure good governance.

•A number of policies and procedures at the practice were not appropriately reviewed, dated or contained up to date or practical information. We saw that some policies contained conflicting or misleading information.

•The practice did not have a fully functioning and embedded system in place to safely manage the appropriate use, distribution and storage of prescription stationery in line with NHS Protect guidance.

•The practice did not conduct clinical audits or quality improvement activity.

•On the day of inspection, we saw evidence of one clinical meeting, one multi-disciplinary team meeting and two nurse meetings in 2018. We were not assured regular clinical meetings took place. Meetings minutes were unstructured and we saw that issues such as safeguarding, complaints and significant events were not discussed with the staff team.

The areas where the provider must make improvements are:

•Ensure that care and treatment is provided in a safe way to patients.

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

•Ensure that persons employed by the service are suitably trained as is necessary to enable them to carry out the duties they are required to perform.

The areas where the provider should make improvements are:

•Review and improve the approach to the management of test results and implement a clinically led protocol to guide staff to which results or correspondence require a clinical over view.

•Review, improve and encourage the uptake of screening by patients registered with the practice, including cervical, breast and bowel screening.

After the inspection on the 24 October 2018, we wrote a formal letter to the provider. This involved an incident which was being handled by the provider as a complaint. We requested the provider forward a copy of any investigation, findings or applied learning which may occur as a result of a further review of this incident.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

18 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this practice on the 18 November 2014 as part of our comprehensive inspection programme.

We found that the practice had made provision to ensure care for people was safe, caring, responsive, effective and well-led and we have rated the practice as good overall.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Risks to patients were assessed and well managed.
  • People’s needs were assessed and care was planned and delivered in line with current legislation and local care pathways. The practice worked proactively to identify those patients at risk of developing long term conditions which were specific to their patient population. They had developed services and worked with local schemes to monitor and improve the health of these patients. Staff had received training appropriate to their roles.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. We also saw that staff treated patients with kindness and respect, and maintained confidentiality.
  • Patients said they had difficulty contacting the surgery by telephone but the practice had put systems in place to try to improve this. Urgent appointments were available the same day.
  • There was a clear leadership structure and staff felt supported by management. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on.

There were some areas of practice where the provider needs to make improvements.

  • Administration staff had not had disclosure and barring service (DBS) checks completed although some had received chaperone training and may act as a chaperone on occasion.
  • A wide range of information about the practice and services was provided. However, key documents, such as the practice booklet and complaints procedure, were only available in English which did not meet the needs of some of the patient population.
  • Verbal concerns that were raised by patients and any actions taken were not always recorded.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 May 2014

During an inspection looking at part of the service

Our inspection on the 11 November 2013 found the practice did not have robust systems in place which were designed to assess the risk of and prevent and control the spread of health care associated infections. Following the inspection the provider wrote to us and told us they would take action to ensure they were compliant with these essential standards.

At this inspection we found that improvements had been made. The provider had reviewed their policies and procedures and implemented new systems which assessed the risk of and prevented the spread of health care associated infections.

11 November 2013

During a routine inspection

We talked with three people who used the practice. Two people told us they had found it easy to make both non-urgent and urgent appointments. They felt the receptionists were 'very good' and the appointments had not been rushed. One person told us it was difficult to make telephone appointments because they had to take their children to school from 8am to 9am when most of the appointments were allocated.

We found that people's views about the service were acknowledged and responded to. For example in the GP practice survey results 2012 ' 2013, people were asked if it was difficult to get through on the telephone, 64 people out of 88 responded that it was not easy to contact the practice by telephone. In response we saw the practice planned to improve the telephone system by adding an extra line.

People who used the service were protected against the risk of abuse. Staff had received training in abuse awareness and protecting children and vulnerable adults. Policies and procedures were available to all staff in relation to safeguarding.

We also found the practice was following their recruitment process and had carried out all the appropriate checks before staff had started work.

We looked at the premises and found the practice did not have robust systems in place which were designed to assess the risk of and prevent and control the spread of health care associated infections.