• Doctor
  • GP practice

Dr Mahmood & Partners

Overall: Good read more about inspection ratings

Ravensthorpe Health Centre, Netherfield Road, Ravensthorpe, Dewsbury, West Yorkshire, WF13 3JY (01924) 767282

Provided and run by:
Dr Mahmood & Partners

Latest inspection summary

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Background to this inspection

Updated 20 February 2024

Dr Mahmood and Partners is located within Ravensthorpe Health Centre, Netherfield Road, Ravensthorpe, Dewsbury, West Yorkshire WF13 3JY. The premises are purpose-built and shared with other healthcare providers, including a GP practice. The practice utilises 4 consultation rooms.

The practice is situated within the West Yorkshire Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of 4,393.

The practice is registered as a partnership with the Care Quality Commission (CQC) to deliver the regulated activities diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.

The practice is part of a wider network of GP practices called a Primary Care Network (PCN) which includes 5 GP practices and is called the Three Centres Primary Care Network (PCN).

The practice is open between 8am to 6pm Monday to Friday. When the practice is closed, patients are directed to contact NHS 111 for out-of-hours care. Pre-bookable extended access appointments are provided by Curo Health at locations in the area. Appointments are available on Monday to Friday from 6.30pm to 9.30pm, on Saturday from 9am to 4pm and on Sunday from 9am to 1pm.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the lowest decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 62% Asian, 31% White, 1% Black, 3% Mixed, and 3% Other.

The provider is a partnership with 2 GP partners (1 male and 1 female). The clinical team includes 3 advanced nurse practitioners (2 employed and 1 locum), 1 locum advanced clinical practitioner, 3 practice nurses and 1 healthcare assistant. They are supported by a practice manager, a reception manager and 6 reception/administrative staff.

Overall inspection

Good

Updated 20 February 2024

We undertook an announced targeted assessment of the responsive key question at Dr Mahmood & Partners on 23 January 2024.

We have rated the responsive key question as requires improvement as feedback from some people who used the service indicated that they were not always able to access care and treatment in a timely way. Although we saw the practice was attempting to improve access, this was not yet reflected in the National GP Patient Survey data or other sources of patient feedback. Our ratings depend on evidence of impact and must reflect the lived experience that people were reporting at the time of inspection.

As the other domains were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain good.

Safe – Not inspected, rating of Good carried forward from previous inspection

Effective - Not inspected, rating of Good carried forward from previous inspection

Caring - Not inspected, rating of Good carried forward from previous inspection

Responsive – Requires Improvement

Well-led - Not inspected, rating of Good carried forward from previous inspection

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Mahmood & Partners on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people.

Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the inspection

This assessment was carried out remotely. It did not include a site visit. The process included:

  • Conducting an interview with the provider using video conferencing.
  • Reviewing patient feedback from a range of sources
  • Requesting evidence from the provider.
  • Reviewing data we hold about the service
  • Seeking information/feedback from relevant stakeholders

Our findings

We based our judgement of the responsive key question on a combination of:

  • what we found when we spoke with the provider
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • Feedback from some patients indicated they were not always able to access care and treatment in a timely way. Data from the National GP Patient Survey showed the practice performed below local and national averages for all of the indicators related to access, and on a downward trend.
  • The provider organised and delivered services to meet patients’ needs.
  • Complaints were listened to, managed appropriately and used to improve the quality of care.

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

  • Continue to monitor and take steps to improve telephone and appointment access.
  • Review the practice website with regards advice for patients on how to access appointments and complaints management.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care