Dr Ahmad and Partners Also known as Alexander House Health Centre

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

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice had systems in place to support safe environments, including a business continuity plan which staff reported was regularly reviewed and accessible electronically. Fridge temperatures and emergency medicines were checked regularly however we noted that there were some months were the emergency medicines had not been checked.

Inspection findings identified several gaps in environmental and safety oversight. The fire risk assessment available related only to shared areas of the building, fire marshal training had not been completed, and the practice manager confirmed they had not previously seen some fire safety and servicing documentation held by the building owner. This limited assurance that leaders had effective oversight of premises-related risk.

There was no practice COSHH file or evidence of completed COSHH risk assessments. However, after the inspection the practice sent in a COSHH risk assessment for the cleaning materials used by the practice. Prescription stationery was not consistently stored securely, with prescription pads and printed prescriptions observed in unlocked areas. The practice updated their blank prescription policy after the inspection which stated that prescriptions would be signed in and out daily. We also found out of date consumables in one clinical room. We noted that there was no reasonable adjustment risk assessment in place. Legionella water temperature monitoring was not being completed.

The service had contracts to ensure the premises was maintained and we observed the premises to be clean. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.
 

The practice had arrangements in place to maintain staffing levels and manage workforce pressures. Staff reported that relief staff were available to support service delivery, administrative staff provided cover during periods of sickness, and additional shifts could be undertaken where required. The practice reported sufficient GP and nursing capacity, with plans to recruit a nursing associate. Locum GPs were used when required, and leaders stated they generally utilised clinicians known to the practice.

The practice had systems in place to monitor staff training through an electronic training platform and a training matrix. However, staff training records identified significant gaps in completion rates and mandatory training compliance. Some staff had low completion rates on the training system, including clinical staff. Mandatory training in areas such as safeguarding, infection prevention and control, information governance, legionella awareness and first aid had expired for some staff members. Fire safety training had only been completed by one member of staff, and the provider could not demonstrate that all staff had completed autism awareness training.

Recruitment files did not consistently contain all information required to demonstrate staff suitability. For example, one GP file did not contain evidence of qualifications. Newly recruited administrative and reception staff had commenced employment before all pre-employment checks had been completed. Missing information included references, proof of identity, DBS checks and employment history documentation. One staff member had started employment without a CV, DBS check, references or proof of identity being available within their file at the time of inspection, although the practice did inform us this information had been requested.

The premises were observed to be visibly clean, including patient and staff toilets, waiting areas and clinical curtains. Paper couch rolls were used, and sharps bins were available in treatment rooms. A sharps injury policy and waste disposal arrangements were in place. Staff reported that IPC audits were undertaken annually and IPC was discussed during staff meetings.

However, some concerns were identified regarding infection prevention and control governance. Out-of-date syringes were found in a doctor's room, some sharps bins were unsigned and undated, and no infection control audits or hand hygiene audits were available for several years prior to 2026. The IPC lead was unable to confirm recent IPC training, and there was limited evidence of ongoing competency development. The IPC policy referred to monthly checks, but supporting records were not available.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences in line with national guidance. The practice delivered good medicines optimisation by mostly embedding robust, proactive safety reviews that ensured people received evidence-based, clinically effective, and safe prescribing.

The practice had a number of systems in place to support the safe management of medicines. Patient Group Directions (PGDs) were available for nursing staff, were signed, in date and subject to appropriate authorisation processes. Vaccine fridge temperatures were monitored daily and a sample review confirmed vaccines were within their expiry dates. Emergency medicines and equipment were checked regularly, with all emergency medicines found to be in date at the time of inspection. Oxygen stocks were monitored monthly and were observed to be adequately stocked. The practice also undertook structured medication reviews for patients receiving repeat medicines and monitored prescribing through clinical audit activity, including antimicrobial prescribing audits completed in conjunction with the PCN.

The clinical records we reviewed demonstrated that medications were being monitored in line with guidance, and we found that medicine alerts were being actioned accordingly. The records demonstration that medication reviews had been completed in the last 3 months and were clearly documented. We found that high risk medicines such as methotrexate were prescribed in line with guidance.