Background to this inspection
Updated
10 August 2021
The Balaji Surgery is located within Sparkbrook Medical Centre, which is a large modern health centre in Sparkbrook, Birmingham at:
34 Grantham Road
Birmingham
B11 1LU.
The surgery has good transport links and there is a pharmacy located in the centre.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, surgical procedures and treatment of disease, disorder or injury.
The Balaji Surgery is situated within the Birmingham and Solihull Commissioning Group (CCG) and provides services to approximately 2,900 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
The practice registered with the CQC in 2018 as a partnership, previously the practice was run by a single handed male GP. The practice has two GP partners (one male and one female). The GPs are supported by a health care assistant and a part time nurse. There is part time practice manager who is supported by an IT manager, assistant practice manager and a team of administrative staff.
The National General Practice Profile states that 66.9% of the practice population is from an Asian background. Information published by Public Health England rates the level of deprivation within the practice population group as one, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The practice opening times are:
Monday: 8am - 8pm
Tuesday: 8am - 6.30pm
Wednesdy: 8am - 6.30pm
Thursday: 8am - 6.30pm
Friday: 8am - 6.30pm
Appointments are available from:
Monday: 9am-12pm and 4pm-7pm
Tuesday: 9am-12pm and 3.30pm - 6pm
Wednesday: 9am-12pm and 3.30pm -6pm
Thursday: 9am-12pm and 3.30pm - 6pm
Friday 9am-12pm and 2pm - 5pm
Weekend appointments are available through the Federation at a HUB centre (Sparkhill Primary Care Centre, 856 Stratford Road, Birmingham, B11 4BW).
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.
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. If the GP needs to see a patient face-to-face then the patient is offered this.
Updated
10 August 2021
For providing
We carried out an announced inspection at The Balaji Surgery on 17 July 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective – Requires improvement
Caring - Good
Responsive – Good
Well-led - Good
Following our previous inspection in May 2019, the practice was rated Requires Improvement for safe, caring, responsive and well-led and rated requires improvement overall. The service was rated good for effective.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Balaji Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to follow up on:
-
Safe, effective, responsive, caring and well-led key questions.
-
The breaches previously identified at our inspection in May 2019
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 for providing safe, caring, responsive and well-led services and good overall. For providing effective services we have rated the practice as requires improvement. We have rated the population groups people with long term conditions, families, children and young people and working age people (including those recently retired and students) as requires improvement. All other population groups were rated good.
We found that:
- The practice had improved systems and processes to provide care in a way that kept patients safe and protected them from avoidable harm. However, further improvements were required to ensure strong processes to protect vulnerable children.
- Patients received effective care and treatment that met their needs, although some areas needed further improvement including uptake rates for cervical cytology, childhood immunisation and some areas of long term conditions management.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. The practice had increased appointments to improve access to care. Whilst this had yet to impact fully on the national GP patient survey, we saw that there were some improvements.
- The leadership and management team were aware of the challenges and areas for improvement and had implemented actions to promote the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Improve cervical cytology and childhood immunisation uptake.
- Where patients are managed by secondary care, implement appropriate documentation to evidence that up to date blood test results were checked before prescribing medicine.
- Develop effective processes to ensure children under safeguarding concerns are linked appropriately so that staff are aware of potential risks.
- Improve Personalised Care Adjustment (PCA) rates for patients with dementia so that they are within local and national averages.
- Improve process for effective management of patients with diabetes.
- Document reviews of competency undertaken with the healthcare assistant (HCA) undertaking dementia and asthma checks.
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