Dr Joann Amin Also known as The Willows Surgery

Updated 21 September 2023

Dr Joann Amin, also known as The Willows Medical Practice, is located in Salford at:

The Willows Medical Practice

Lords Avenue

Salford

Manchester

M5 5JR

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Greater Manchester Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 3610. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices in the Salford South East primary care network (PCN).

Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one 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 87.2% White, 5.4% Asian, 4.2% Black, 2.3% Mixed and 0.9% Other.

The age distribution of the practice population closely mirrors the local and national averages.

There is one GP and one advanced nurse practitioner who provide cover at the practice. The practice is a training practice and regularly has student doctors provide care and treatment at the practice. The practice has one long term locum nurse who provides nurse led clinics for long-term conditions. The GP is supported at the practice by a team of reception/administration staff. There is a practice manager to provide managerial oversight.

The practice is open between 8:30am to 6:30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Updated 21 September 2023

We previously carried out an announced inspection at Dr Joann Amin on 22 July 2022. At that earlier inspection, the practice was rated as requires improvement with the following key question ratings:

Safe - requires improvement

Effective – requires improvement

Caring – good (rating awarded at the inspection 24 May 2016)

Responsive – good (rating awarded at the inspection 24 May 2016)

Well-led – requires improvement

We found breaches of Regulation 17 (Good governance) and 19 (Fit and proper persons employed).

At this inspection, on 27 June 2023, we found improvements had been made to the service, but further improvement was required. We have rated the practice as good overall; the key questions of safe, caring, responsive and well led are rated as good. We have rated effective as requires improvement. We found a breach of Regulation 12 (Safe care and treatment).

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

Why we carried out this inspection

We carried out a full comprehensive inspection in response to risk as the last inspection rated the practice as requires improvement overall.

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 was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews remotely.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Requesting evidence from the provider.
• A short site visit.
• Gaining feedback from staff by using staff questionnaires.

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 good overall.

We rated the practice good for providing safe services:

• Recruitment checks were carried out in accordance with regulations.
• The system for receiving and acting on safety alerts was effective.

We rated the practice requires improvement for providing effective services:

• Dementia care plans were not effective.
• Patients with long-term conditions were not always effectively monitored.
• The practice did not consistently record repeated consent to care and treatment in line with legislation and guidance.

We rated the practice good for providing caring services:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice good for providing responsive services:

• Patients could access care and treatment in a timely way.

We rated the practice good for providing well-led services:

• Governance and assurance systems had improved since our last inspection.

We found a breach of regulation. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Continue efforts to improve the take up of childhood immunisations and cervical screening programmes.

• Undertake a review of the approach to the recording and review of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decision making and recording and be assured that an appropriate policy is in line with current practice guidelines.

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