The Care Quality Commission
  • Doctor
  • GP practice

Dr Deedar Singh Bhomra Also known as Aylesbury Surgery

Overall: Good read more about inspection ratings

Aylesbury Surgery, Warren Farm Road, Kingstanding, Birmingham, West Midlands, B44 0DX 0845 675 0563

Provided and run by:
Dr Deedar Singh Bhomra

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Dr Deedar Singh Bhomra on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Dr Deedar Singh Bhomra, you can give feedback on this service.

4 August 2022

During a routine inspection

We carried out an announced comprehensive inspection at Dr Deedar Singh Bhomra on 4 August 2022. The practice is rated as good overall.

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

We carried out an announced follow up inspection at Dr Deedar Singh Bhomra (also known as Aylesbury Surgery) in April 2018 where the practice continued to be rated as requires improvement for providing safe services and breaches of regulations were identified. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements.

We undertook a further follow up inspection in December 2018 to check whether the provider had taken action to meet the legal requirement’s’ as set out in the requirement notices. We found that the provider had taken appropriate action to meet the legal requirements and was rated good in all areas. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Deedar Singh Bhomra on our website at www.cqc.org.uk

Why we carried out this inspection:

We undertook this inspection on 4 August 2022 as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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 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 provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
  • The practice had a system for recording and disseminating actions carried out as a result of significant events to support learning and improvement.
  • The practice had taken appropriate action to support and protect patients identified as at risk from harm.
  • Patients received effective care and treatment that met their needs.
  • Verified data showed that the practice had exceeded the 90% minimum uptake target for childhood immunisations in all age groups.
  • National prescribing data showed that the practice prescribing for some antibiotics, hypnotics and other medicines and medicines to manage a patients behaviour, mood or thoughts was higher than other practices locally and nationally.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The results of the National GP Patients survey identified that patients had a positive experience of the practice and felt there was access to timely care and treatment.
  • The practice had management oversight of staff qualifications and training.
  • Staff were clear and knowledgeable about their lead roles and responsibilities.
  • Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
  • There was a high uptake by patients of preventative treatments and screening procedures. This was particularly in the areas of childhood immunisations and cervical screening.
  • The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centred care.
  • The practice was actively involved in the local community.
  • Staff understood and engaged with various community groups building confidence and trust with the whole practice population.

We saw areas of outstanding practice:

  • The practice actively worked with patients, residents and community organisations to encourage community spirit and involvement in various events. For example;
  • Children from the local primary schools continued to visit the practice where staff delivered short talks to provide an insight of visiting a GP practice.
  • The provider has continued to fund and facilitate access to a hot meal every month for people in the local community. Staff told us that the event was well attended, the number of people that attended had increased from sixty to approximately 150 over the past few years. The practice supported as well as arranged fund raising events, which collected donations to support local organisations.
  • Practice staff were proactive in promoting the uptake of cervical screening. This had supported them to maintain the uptake of cervical screening above the England 80% target for over five years. The data showed that this uptake had been maintained during the COVID-19 pandemic.
  • The outcome of the GP National patient survey for the practice showed that patient responses were significantly higher than the local and national averages. The practice specifically scored over 90% in all five indicators, relating to their experience of the care they received at the practice.

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

  • Review and monitor its medicine prescribing practices for antibiotics and medicines used to help patients sleep or manage their behaviour.
  • Review the systems in place for monitoring safety alerts to demonstrate that best practice guidance is followed in managing medicines.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

3 January

During an inspection looking at part of the service

This practice is rated as Good overall. (Previous rating April 2018 – Good overall, with a rating of requires improvement for providing safe services)

The key questions at this inspection are rated as:

Are services safe? – Good

We carried out an announced comprehensive inspection at Dr Deedar Singh Bhomra (also known as Aylesbury Surgery) in December 2016 where the provider was rated as requires improvement for providing safe services and breaches of regulations were identified. We undertook a follow up inspection in April 2018 the practice continued to be rated as requires improvement for providing safe services. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements. The full comprehensive report of all previous inspections can be found by selecting the ‘all reports’ link for Dr Deedar Singh Bhomra on our website at

This inspection was an announced focused follow up inspection carried out on 3 December 2018 to check whether the provider had taken action to meet the legal requirement’s’ as set out in the requirement notices. The report covers our findings in relation to those requirements.

At this inspection we found:

  • Staff demonstrated awareness of systems to manage risks so that safety incidents were less likely to happen. When incidents did happen, the practice demonstrated shared learning and the actions taken to improve processes.
  • Since the inspection in April 2018, the practice had reviewed and improved the management of risks in areas such as health and safety.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

11/04/2018

During a routine inspection

This practice is rated as Good overall. Previous inspection December 2016 and rated overall good, except for providing safe services where the practice was rated as requires improvement. This was because action required to comply with findings from annual infection control audits had not been fully addressed. For example, provisions of a sluice hopper for the disposal of waste water and a hand wash basin in the area used to store cleaning equipment. Systems for monitoring prescription collection were not embedded.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? – Good

We carried out an announced comprehensive inspection at Dr Deedar Singh Bhomra also known as Aylesbury Surgery on 11 April 2018 as part of our inspection programme.

  • The practice had clear systems to respond to incidents and measures were taken to ensure incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice did not carry out some risk assessments. For example, a fire and health and safety risk to support the monitoring or mitigation of potential risks had not been carried out. However, staff explained that monthly walk arounds to check health and safety within the practice were carried out and, where required, actions had been taken.
  • The practice had some arrangements in place to enable appropriate actions in the event of a medical emergency. However, not all potential medical emergency situations were considered and a risk assessment to mitigate potential risks had not been carried out. Following our inspection, the practice reviewed and updated their stock of emergency medicines.  
  • 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. Results from the July 2017 national GP patient survey showed that the practice scored above local and national averages in a number of areas. Completed Care Quality Commission (CQC) comment cards were also positive about the services provided.
  • Completed CQC comment cards showed that patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning, improvement and community engagement at all levels of the organisation. The leadership team maintained an inspiring shared purpose and strived to deliver the vision while motivating staff to succeed.

We saw areas of outstanding practice:

The practice used their knowledge of the local community and patient population as levers to deliver high quality, person centred care. Staff were well organised and made full use of their resources to respond to population needs. There was a strong focus on community involvement, for example:

  • Children from local primary schools were invited to the practice where staff delivered short talks to provide an insight of visiting GPs. Staff with the help of teachers gave children demonstrations on how GPs carries out checks and children were able to see equipment used in the surgery. Discussions with the local church highlighted a concern that people within the area did not always have access to a hot meal. In response to this, the practice funded a monthly soup kitchen in the local Church Hall. Staff we spoke with explained that this was well attended. The practice actively worked with patients, residents and community organisations to encourage community spirit and involvement in various events. For example, the practice supported as well as arranged fund raising events, which collected donations to support local organisations.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Ensure staff are aware of forms used by the practice to report incidents.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

7 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Aylesbury Surgery on 07 December 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and staff used an effective system to report significant events. The practice could demonstrate learning from investigations.
  • Risks to patients were assessed and well managed with a particularly acute focus on risks associated with vulnerable children and patients with mental health needs.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. A system was in place to ensure clinical staff maintained an up to date knowledge of changes in national guidance, including from the National Institute of Health and Care Excellence.
  • Patients feedback was consistely positive and the practice performed significantly better than local and national averages in the GP Patient Survey.
  • Staff had established a clinical audit programme based on the performance of the practice and the needs of its patients and used results to improve services.
  • 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 and the practice manager followed up each complaint personally.
  • The practice offered a range of appointments to suit patients’ needs and to ensure continuity of care.
  • The practice had good facilities and was well equipped to treat patients, with adaptations made based on patient feedback.
  • The leadership structure meant staff felt supported and valued, which helped them to give their best. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider complied with the requirements of the duty of candour.

We saw areas of outstanding practice:

  • There was a consistent and proactive approach to engaging with the local community. This included the implementation of a community health forum to help drive health improvement and provide patients with links to multiprofessional services such as local authority safeguarding and the police. In addition, the service funded and facilitated a monthly communal hot meal for people in the local community.

The areas where the provider should make improvements are:

  • The practice should ensure every member of staff has the knowledge and skills to access clinical policies and guidance on the electronic system, including how to flag and identify patients at risk. There should also be a system in place to ensure staff follow policies and ensure newly implemented guidance is embedded in the service.
  • The practice should implement monitoring to ensure the chaperone policy implemented after our inspection was implemented consistently.
  • The practice should implement a system to actively identify and support carers within their patient list, as this was at less than 1% at the time of our inspection.
  • The practice should encourage patients to engage with national screening programmes for breast and bowel cancer

We found two areas in which the provider must make improvements:

  • The provider must ensure the actions resulting from the 2016 infection control audit are fully implemented.
  • The provider must ensure storage facilities used for infection control equipment are secured and fit for purpose, with documented evidence of regular reviews to establish effectiveness.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice