Background to this inspection
Updated
14 June 2021
Dr Waleed Doski’s practice (also known as Bournville Surgery) is situated at 41B Sycamore Road, Bournville, Birmingham, West Midlands, B30 2AA. The premises are situated in a converted bakery in the village of Bournville.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the Birmingham and Solihull Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 2400. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices (Primary Care Network).
The practice team consists of a GP (male), a practice nurse and a health care assistant (both female), as well as a practice manager and administrative and reception staff. The practice had difficulty recruiting a manager and the current manager was supporting on a peer support basis through the CCG.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. However, the practice had just started to offer face to face appointments following easing of lockdown legislation.
The practice is open for appointments between 8am and 6.30pm Tuesday to Friday, on Mondays the practice is open for appointments from 8am to the later time of 7.30pm when the practice offers extended hours. Appointments are available from 8am until 1pm and then from 3pm until 6pm on weekdays, except for Mondays when evening appointments are available. The practice has primary care cover during the afternoons when appointments are closed, during these times telephone lines are diverted to the SouthDoc service. Extended hours are also available to patients each evening at local hub centres through the MyHealthcare federation until 8pm, on Saturday from 7am to 6pm and Sundays from 9am until 12pm. At all other times, patients are referred to the NHS 111 service or the local walk in centre.
Updated
14 June 2021
We carried out an announced inspection at Dr Waleed Doski on 18 May 2021. Overall, the practice is rated as good.
Safe - Good
Effective - Good
Caring – good (carried over from previous inspection)
Responsive – good (carried over from previous inspection)
Well-led – Good
Following our previous focussed inspection, on 12 November 2019, the practice was rated Requires Improvement overall (good for effective, requires improvement for safe and well-led).
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Waleed Doski on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focussed inspection to follow up on:
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Safe, effective and well-led key question
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We followed up on the breaches previously identified
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We carried forward ratings for caring and responsive from previous inspections as the information we held did not indicate any change to ratings.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short 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 have rated this practice as Good overall and good for all population groups except working age people, which we rated as requires improvement because;
- Cervical cancer screening data was below the national average and sufficient improvements had not been made over time.
We found that:
- The practice had acted on findings from our previous inspection in November 2019 and have made significant improvements.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. The practice had made improvements to issues we had identified previously.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Whilst governance processes were being established and embedded, there were some areas of risk management and performance of the practice that required further strengthening.
Whilst we found no breaches of regulations, the provider should:
- Ensure Personalised Care Adjustment (PCA) rates for patients with long term conditions such and diabetes and COPD are within local and national averages.
- Continue to improve on childhood immunisation and cervical cytology targets.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care