Archived: Derby Family Medical Centre

Updated 22 May 2020

Al-Quddoos Limited operates from the premises of Derby Family Medical Centre, an NHS GP practice which was inspected by the CQC on 15 December 2017 and assessed through our annual regulatory review process in December 2018.

Al-Quddoos Limited has a service level agreement with Derby Family Medical Centre, the location from which they operate, to use two treatment rooms, sluice room, reception area and waiting room. They provide faith and non-faith based non-therapeutic circumcision services for boys up to the age of five years old.

The service is provided by a lead clinician (male), who is supported by a volunteer assistant (male) who is present during all procedures. The role of the assistant is to prepare the treatment room and assist with note taking as necessary during the procedures. They are supported by a newly employed service manager (female), two receptionists (female) and two booking clerks (female), one of whom is in a voluntary role.

The booking clerks are based at the registered address of the company and not at the location where the procedures take place. The lead GP and the service manager are the registered managers of the service. The patients seen at the practice are often seen for single treatments and as such the clinic does not keep a patient list. The service is open on a Saturday and sometimes on a Sunday dependent on demand, seeing approximately 10 patients each day and up to 50 patients utilise the service each month. They do not provide any home visits. On days when the service is open, they operate from approximately 10am until 6pm.

The service is registered with the CQC to provide surgical procedures.

How we inspected this service

As part of our inspection we asked for CQC comment cards to be completed by patients prior to our inspection.

During the inspection we utilised a number of methods to support our judgement of the services provided. For example, we interviewed staff, and reviewed documents relating to the service.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 22 May 2020

• The service had previously been inspected in March 2018 and was found to be providing services in accordance with relevant regulations. At that time independent providers of regulated activities were not rated by the Care Quality Commission. At the previous inspection the provider was informed that they should consider the following improvements;

  • Develop an appraisal system to support the development of staff.
  • Improve the recording of minutes of meetings undertaken with staff.
  • Develop the provision of information in other languages for patients who may have limited knowledge of the English language.

  The key questions are rated as:

  Are services safe? – Requires improvement

  Are services effective? – Good

  Are services caring? – Good

  Are services responsive? – Good

  Are services well-led? – Requires improvement

  We carried out an announced comprehensive inspection at Derby Family Medical Centre as part of our inspection programme.

  The single practitioner and the service manager are the registered managers and leaders of this service. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

  We collected 13 comment cards that had been completed by patients at the previous week’s clinics. All comment cards were positive about the service and the manner in which patients were treated.

  Our key findings were :

  • The provider was able to demonstrate comprehensive safeguarding systems were in place and recruitment procedures kept patients safe. We found concerns in relation to systems in place to manage risk to patients in that they were not working effectively.
  The provider delivered services within guidelines and used up to date methodology. The provider engaged in clinical audits to ensure that patients were experiencing positive outcomes.
• The service offered three separate opportunities for patients to feedback in a structured way as well as considering free text and verbal feedback as well. Feedback we received was generally positive about access to the service and about how they felt they were treated by staff.
• The provider was unable to demonstrate that all appropriate systems or processes had been established or were working as intended to support the safety of staff or service users. We found that the provider had acted to ensure information was provided to patients in languages other than English, according to the needs of their population. They were also able to demonstrate that they had recorded minutes of meetings held with staff but could not demonstrate that they had taken any action taken to address the lack of appraisals to develop and support staff, which was a should from the previous report.

The areas where the provider must make improvements as they are in breach of regulations are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Establish a system to ensure patient’s GPs are directly communicated with by the provider.
• Develop an appraisal system and embed it into the development and support for all staff.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care