We carried out an announced comprehensive inspection at Dr Deedar Singh Bhomra on 4 August 2022. The practice is rated as good overall.
Safe – Good
Effective – Good
Caring – Good
Responsive – Good
Well-led – Good
We carried out an announced follow up inspection at Dr Deedar Singh Bhomra (also known as Aylesbury Surgery) in April 2018 where the practice continued to be rated as requires improvement for providing safe services and breaches of regulations were identified. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements.
We undertook a further follow up inspection in December 2018 to check whether the provider had taken action to meet the legal requirement’s’ as set out in the requirement notices. We found that the provider had taken appropriate action to meet the legal requirements and was rated good in all areas. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Deedar Singh Bhomra on our website at www.cqc.org.uk
Why we carried out this inspection:
We undertook this inspection on 4 August 2022 as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.
How we carried out the inspection:
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A site visit.
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 found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
- The practice had a system for recording and disseminating actions carried out as a result of significant events to support learning and improvement.
- The practice had taken appropriate action to support and protect patients identified as at risk from harm.
- Patients received effective care and treatment that met their needs.
- Verified data showed that the practice had exceeded the 90% minimum uptake target for childhood immunisations in all age groups.
- National prescribing data showed that the practice prescribing for some antibiotics, hypnotics and other medicines and medicines to manage a patients behaviour, mood or thoughts was higher than other practices locally and nationally.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The results of the National GP Patients survey identified that patients had a positive experience of the practice and felt there was access to timely care and treatment.
- The practice had management oversight of staff qualifications and training.
- Staff were clear and knowledgeable about their lead roles and responsibilities.
- Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
- There was a high uptake by patients of preventative treatments and screening procedures. This was particularly in the areas of childhood immunisations and cervical screening.
- The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centred care.
- The practice was actively involved in the local community.
- Staff understood and engaged with various community groups building confidence and trust with the whole practice population.
We saw areas of outstanding practice:
- The practice actively worked with patients, residents and community organisations to encourage community spirit and involvement in various events. For example;
- Children from the local primary schools continued to visit the practice where staff delivered short talks to provide an insight of visiting a GP practice.
- The provider has continued to fund and facilitate access to a hot meal every month for people in the local community. Staff told us that the event was well attended, the number of people that attended had increased from sixty to approximately 150 over the past few years. The practice supported as well as arranged fund raising events, which collected donations to support local organisations.
- Practice staff were proactive in promoting the uptake of cervical screening. This had supported them to maintain the uptake of cervical screening above the England 80% target for over five years. The data showed that this uptake had been maintained during the COVID-19 pandemic.
- The outcome of the GP National patient survey for the practice showed that patient responses were significantly higher than the local and national averages. The practice specifically scored over 90% in all five indicators, relating to their experience of the care they received at the practice.
Whilst we found no breaches of regulations, the provider should:
- Review and monitor its medicine prescribing practices for antibiotics and medicines used to help patients sleep or manage their behaviour.
- Review the systems in place for monitoring safety alerts to demonstrate that best practice guidance is followed in managing medicines.
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 Hospitals and Interim Chief Inspector of Primary Medical Services