The Care Quality Commission
  • Doctor
  • GP practice

Archived: The OM Surgery

Overall: Requires improvement read more about inspection ratings

112 Watnall Road, Hucknall, Nottingham, Nottinghamshire, NG15 7JP (0115) 963 2184

Provided and run by:
Dr Suman Mohindra

Important: The provider of this service changed. See new profile

All Inspections

During an assessment under our new approach

The OM Surgery is an NHS GP practice located in Nottingham. The practice was last rated Good (published 1 April 2019). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment: Single Assessment Framework (SAF).

We carried out an unannounced on-site assessment on 20 March 2024 of 6 quality statements: Learning culture; Safe environments; Safe and effective staffing; Infection prevention and control; Freedom to speak up; Governance, management and sustainability. The quality statements were selected based on concerns received by CQC relating to safety and governance systems at the practice.



We assessed some but not all quality statements at this visit which means we use the ratings from the previous inspection to rate the key questions of safe, effective, caring, and well led. This assessment did not cover all parts of our SAF, therefore we have only updated scores and ratings for those areas which we have assessed. We will carry out future assessments to cover other parts of the Framework and will update our website with our findings.

The provider and management had changed in October 2023 following a transfer of the NHS contract to the new provider. At the assessment we found the provider failed to demonstrate a proactive approach in managing safe and well led services. There was limited evidence systems in place promoted a learning culture. We found systems for managing premises and environmental risks were not effective. The practice did not ensure appropriate standards of cleanliness and hygiene were met in line with regulations. Leaders and management had no oversight of the risks above, which is a breach of regulations 12 (safe care and treatment) and 17 (good governance). The provider is subject to an action plan to remedy the breaches.

21 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at The OM Surgery on 21 February 2019 as part of our inspection programme.

At the last inspection in December 2017 we rated the practice as requires improvement for providing safe and caring services and requires improvement overall because:

  • Patients were potentially at risk of harm because systems relating to medicines safety were not fully effective to keep patients safe.
  • Actions identified in the practice’s legionella action plan had not been completed.
  • Results from the national GP patient survey showed areas of lower than average patient satisfaction in some areas.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The area where the provider should make improvements is:

  • Continue to develop a record of staff immunisation status for all diseases recommended by Public Health England.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

06/12/2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall. (Previous inspection 14/01/2015 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) – Requires improvement

We carried out an announced inspection at The OM Surgery on 6 December 2017 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

  • However, patients were potentially at risk of harm because systems relating to medicines safety were not fully effective to keep patients safe.

  • Some remedial actions identified in the practice’s legionella action plan had not been completed in line with the recommended timescales following a risk assessment.

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

  • Staff involved and treated patients with compassion, kindness, dignity and respect. Feedback from patients we spoke with during our inspection was highly positive about the caring approach of all staff. However, results from the national GP patient survey showed areas of lower than average patient satisfaction in some areas.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • The practice understood the needs of its population and tailored services in response to those needs.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

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

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

The areas where the provider should make improvements are:

  • Address the issues highlighted in the national GP patient survey results in order to improve patient satisfaction particularly in relation to interactions with the GPs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Om Surgery on 14 January 2015. The practice had not previously been inspected.

The overall rating for this practice is good.

Our key findings across all the areas we inspected were as follows:

  • Patients expressed high levels of satisfaction with the care and service they received. They said that they were treated with kindness, dignity and respect and were involved in decisions about their care and treatment.
  • Procedures were in place to help keep patients safe and to protect them from harm.
  • The practice was accessible and well equipped to treat patients and meet their needs.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients were able to access care and treatment when they needed it. They found it easy to make an appointment, with urgent appointments usually available the same day.
  • The practice had an experienced and established staff team who ensured continuity of care and services.
  • Staff felt valued, well supported, and involved in decisions about the practice. They were supported to maintain and develop their skills and knowledge to enable them to carry out their work effectively.
  • The staff team were committed to improving the quality of care and services for patients. Systems in place to assess and monitor the quality of services and to drive improvements were being strengthened.

However there were areas where the provider needs to make improvements.

The provider should:

  • Review the recruitment policy to ensure that information required by law is obtained prior to staff commencing employment at the practice.
  • Ensure all staff are competent to undertake their roles by;

Developing the induction programme to include sufficient information relevant to specific staff roles.

Ensuring the health care assistant has been assessed competent to carry out all delegated health checks and tasks.

Providing appropriate training for relevant staff to carry out chaperone duties.

  • Ensure that information available to patients enables them to understand the complaints process, and includes the contact details of NHS England area team and the Parliamentary and Health Ombudsman.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice