18 January 2024
During an inspection looking at part of the service
We carried out an unannounced focused inspection at Dr Maassarani and Partners on 18 January 2024. We did not award a rating as we did not inspect the whole of the domains.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Maassarani and Partners on our website at www.cqc.org.uk
Why we carried out this inspection
This was a focused inspection following information of concern being received by the Care Quality Commission. We looked at specific information in the following key questions:
- Safe
- Effective
- Well-led
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:
- 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 short site visit.
- Interviews with staff.
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 had merged with another practice since our last inspection and there were interim arrangements within the management structure for the practice.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Further work was required to embed governance systems and oversight of risk into everyday practice.
- Staff supervision and appraisals had not always been completed and a plan was in place to address this.
Whilst we found no breaches of regulations, the provider should:
- Take action to improve systems for support, supervision and appraisals for staff.
- Take action to improve feedback from patients.
- Continue to improve the uptake of cervical cancer screening and childhood immunisations.
- Continue to improve the culture within the practice following the merger and vacant management posts.
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