Pak Health Centre - R Bhatti

Updated 21 April 2023

Pak Health Centre – R Bhatti is located in Birmingham at:

38 Alum Rock Road

Birmingham

B8 1JA

The practice is located in a health centre which is shared with another practice.

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

The practice is situated within the Birmingham and Solihull Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of approximately 5,000 patients. This is part of a contract held with NHS England.

The practice recently joined Washwood Heath Primary Care Network (PCN). A PCN is a wider network of GP practices, that work together to address local priorities.

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 65% Asian, 20% White, 10% Black, 5% Mixed and other minority ethnic.

The practice is a family-based practice consisting of two GP partners (one male and one female) supported by two locum GPs, a practice pharmacist (who is also an independent prescriber), one practice nurse, a locum practice nurse, and a health care assistant. Non-clinical staff include a practice manager and a team of administrative / reception staff.

The practice receives additional staffing support through the PCN which includes another pharmacist / independent prescriber, a healthcare assistant and a social prescriber.

The practice partnership changed following our previous inspection in May 2022, with the retirement of the former senior partner. The practice has been made aware that these changes must be made to their CQC registration to ensure they are correctly registered.

The practice is open between 8am and 6.30pm Monday to Friday. Patients are also able to obtain appointments at the extended access hubs in the evenings and on a Saturday at various practice locations in the area including Pak Health Centre.

The practice offers telephone and face to face appointments that are book on the day or in advance.

When the practice is closed, out of hours services are provided by BADGER.

Updated 21 April 2023

We carried out an announced follow up comprehensive inspection at Pak Health Centre – R Bhatti between 5 January 2023 and 16 January 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - requires improvement

Responsive – requires improvement

Well-led - requires improvement

Following our previous inspection on 24 May 2022, the practice was rated inadequate overall and for the safe, effective and well-led key questions. The caring and responsive key questions were not inspected at this time and the good ratings were carried over from the inspection in September 2019. The practice was placed into special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pak Health Centre – R Bhatti on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on the breaches of regulations and ‘shoulds’ identified in the previous inspection.

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 included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter 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 found that:

• The practice had made significant improvements to their governance arrangements. The practice was actively working with their local Integrated Care Board (ICB) and Royal College of General Practitioners (RCGP) to address improvements needed to keep patients safe and protected from avoidable harm. A comprehensive action plan had been developed to bring about the reforms needed, which the practice acknowledged was work in progress.
• Since the previous inspection, the practice had strengthened the leadership arrangements and had started to embed systems and processes for delivering safe and effective care.
• We saw improvements in areas where we had previously identified concerns, for example safeguarding, infection prevention and control, fire safety, management and learning from incidents, management of workflow and laboratory reports, management of patient safety alerts, medicines management and end of life support. However, we also identified aspects in some of these areas which needed further progress to be made such as completion of actions from the fire safety risk assessment, safeguarding alerts for all household members and action in relation to medicine usage.
• Our clinical searches found improvements in the delivery of effective care and treatment including patients on high risk medicines and most long-term conditions reviewed. However, there were some areas that the practice needed to improve; for example, annual reviews for patients with hypothyroidism. The practice were aware they still had backlogs to address but were prioritising those patients most at risk.
• The uptake of childhood immunisations and cancer screening programmes remained low and a challenge to the practice.
• We found the management of staffing had improved, additional pharmacy support had been obtained as well as social prescribing support from the Primary Care Network they had recently joined. There was a clear plan to focus on future staffing needs and development of existing staff.
• Staff were receiving annual appraisals, supervision and support for their roles. Training records were generally up to date for staff in required training.
• Our conversations with staff and clinical reviews found patients were treated with kindness and respect and involved in decisions about their care. However, the latest National GP Patient Survey data showed a significant fall in patient satisfaction, in particular in relation to questions about patient experience.
• The practice was taking action to try and improve access, through staffing and participation in access improvement schemes through the ICB.
• The way the practice leadership was taking forward actions required to improve the service demonstrated a commitment to the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

• Address any issues identified during our clinical searches of medicines and long-term conditions that required follow up.
• Address issues identified in the latest fire risk assessment in conjunction with the neighbouring practice.
• Continue to take action to improve the uptake of child immunisations and cancer screening programmes.
• Improve the identification and support for carers.
• Take action to improve patient satisfaction in the delivery of care and treatment and implement effective processes to monitor progress.

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

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services