Archived: Dr Satish Kumar Dhamija Also known as Lea Village Medical Centre

Updated 1 February 2017

Dr Satish Kumar Dhamija’s practice also known as Lea Village Medical Centre provides primary care services and to its registered list of approximately 2340 patients. The practice is situated and the inspection was conducted at 98-100 Lea Village, Kitts Green, Birmingham, West Midlands, B33 9SD. The practice catchment area is classed as within the group of the most deprived areas in England relative to other local authorities. For example, income deprivation affecting children was 43% compared to the national average of 20%.

On 1 September 2016 Lea Village Medical Centre began joint working with another nearby practice. The practice itself has one male GP but shares three additional GPs, including one female GP with the nearby practice. There is also a female practice nurse, a practice manager, a senior administrator, a practice secretary and three reception staff. The practice is open between 9am and 6.55pm Monday to Friday except for Thursday afternoons when the practice closes at 1.30pm. Appointments take place from 9.30am to 12.30pm every morning and 2pm to 6pm daily.

The practice is located on two floors, the ground floor contains reception, waiting areas, consulting rooms and treatment rooms, whilst the first floor is used for administration offices. There is step free access into the building and access for those in wheelchairs or with pushchairs.

The practice does not provide an out-of-hours service but has alternative arrangements in place for patients to be seen when the practice is closed. For example, if patients call the practice when it is closed, an answerphone message gives the telephone number they should ring depending on the circumstances. The practice employs the use of the Birmingham and District General Practitioner Emergency Room group (Badger) to provide this out-of-hours service to patients.

Updated 1 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Satish Kumar Dhamija on 30 September 2016. This inspection was in response to our previous comprehensive inspection at the practice on 3 December 2015 where breaches of the Health and Social Care Act 2008 were identified. Previously the practice rated as inadequate overall, placed into special measures and we issued requirement notices to inform the practice where improvements were needed. The practice subsequently submitted an action plan to CQC detailing the measures they would take in response to our findings. The identified breaches found at the previous comprehensive inspection on 3 December 2015 related to the regulations Safe care and treatment; Good governance and Fit and proper persons employed. At our inspection on 30 September 2016 we found that the practice had made significant improvements. The requirement notices we issued following our previous inspection had both been met. The practice is now rated as requires improvement overall.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Blank prescription forms were not securely stored, nor was there a system in place to track these within the practice.
• The treatment room containing a vaccination refrigerator was not locked we also found that the lock for the fridge contained the key.
• Risks to patients were assessed and managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management, however further improvements are still needed to ensure leadership and governance is sustained.
• The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure the proper and safe management of vaccinations to prevent unauthorised access.

The areas where the provider should make improvement are:

• Review arrangements for the security of prescription stationery.

• Ensure a consistent approach in the process and the frequency of defibrillator checks.

• Ensure the practice conducts monthly audits of vaccinations and conducts regular stock checks.

• Review processes for the dissemination and accessibility of Patient Group Directions.

• Review staff files to ensure personnel files contain evidence of appropriate identification checks

• Review its processes to identify all the carers on the practice’s patient list.

• Review its processes concerning contact with bereaved patients.

• Review governance and leadership processes to ensure sustained improvement.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 1 February 2017

The practice is rated as requires improvement for the care of older people. This is because the provider was rated as requires improvement overall. The concerns which led to those ratings apply to everyone using the practice, including this population group.

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• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• Performance for diabetes related indicators was comparable to the national average. For example; the percentage of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months (01/04/2014 to 31/03/2015) was 94% compared to the national average of 88%.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 1 February 2017

The practice is rated as requires improvement for the care of older people. This is because the provider was rated as requires improvement overall. The concerns which led to those ratings apply to everyone using the practice, including this population group.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• 81% of female patients aged 25-64 attended cervical screening within the target period compared with the national average of 82%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We saw examples of joint working with midwives, health visitors and school nurses.

Updated 1 February 2017

The practice is rated as requires improvement for the care of older people. This is because the provider was rated as requires improvement overall. The concerns which led to those ratings apply to everyone using the practice, including this population group.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• The practice kept up to date registers of patient’s health conditions and data reported nationally was that outcomes were comparable to that of other practices for conditions commonly found in older people.

Updated 1 February 2017

The practice is rated as requires improvement for the care of older people. This is because the provider was rated as requires improvement overall. The concerns which led to those ratings apply to everyone using the practice, including this population group.

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 1 February 2017

The practice is rated as requires improvement for the care of older people. This is because the provider was rated as requires improvement overall. The concerns which led to those ratings apply to everyone using the practice, including this population group.

• 88% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the preceding 12 months, which was higher than the Clinical Commissioning Group (CCG) average of 82% and the national average of 84%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• The practice carried out advance care planning for patients with dementia.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff had understanding of how to support patients with mental health needs and dementia however; exception reporting in this area was above both CCG and national averages by between 10.3% and 21.5%.

Updated 1 February 2017

The practice is rated as requires improvement for the care of older people. This is because the provider was rated as requires improvement overall. The concerns which led to those ratings apply to everyone using the practice, including this population group.

• The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.