The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Uday Abhyankar Also known as Holly Road Surgery

Overall: Good read more about inspection ratings

139 Hamstead Road, Handsworth, Birmingham, West Midlands, B20 2BT (0121) 551 1062

Provided and run by:
Dr Uday Abhyankar

All Inspections

1 June 2018

During an inspection looking at part of the service

This practice is rated as Good overall. (Previous inspection March 2017 – Good overall, with requires improvement rating for providing Responsive services)

The key questions are rated as:

Are services responsive? – Good

We carried out an announced focused inspection at Dr Uday Abhyankar's practice (also known as Holly Road Surgery) on 1 June 2018. This inspection was in response to our previous comprehensive inspection at the practice in March 2017, where breaches of the Health and Social Care Act 2008 were identified. You can read the report from our last comprehensive inspection on 15 March 2017; be selecting the 'all reports' link for Dr Uday Abhyankar on our website at www.cqc.org.uk.


During this inspection in June 2018, we found the provider was in breach of the Care Quality Commission (Registrations) Regulation 2009 – Regulation 15 Notice of Changes due to the provider not having advised the CQC that their registration status had changed from a single-handed GP to a partnership as of October 2017.

Our key findings were as follows:

  • We saw the provider had acted to improve on the areas we had identified during our previous inspection. For example, the new partnership had increased face to face consultations and nursing staff hours to manage patient demand and at peak times the number of appointments were increased to reduce patients’ waiting times.
  • The management team told us they were currently in the process of changing the telephones with a new system being introduced in June 2018 to further improve access.
  • The practice now provided extended hours appointments through the local commissioning group federation Improved Access Scheme (ICOF). This included appointments outside of the practice opening hours and weekend appointments.
  • The practice had achieved higher than average results for several aspects of care from the 2017 National GP Patient survey.
  • The practice had continued to review their carers register and encouraged patients to identify themselves if they had caring responsibilities. We saw the number of patients on the practice's carers register had increased from 1% to 2%.
  • At our previous inspection, the practice's uptake for the cervical screening programme was lower than the national average. The practice had increased the availability of the practice nurse and patients could also access appointments at other practices the provider was working with locally. The practice had seen an increase in the number of patients attending appointments and had a system in place to follow up on patients who had not attended their appointments, however results remained lower than the national average.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

15 March 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Uday Abhyankar on 30 June 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Dr Uday Abhyankar on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 30 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • During our comprehensive inspection on 30 June 2016 we found that the practice had not shared learning from incidents with the wider team. When we inspected the practice in March 2017 we saw the practice had reviewed its system for managing incidents. The practice was able to demonstrate that learning from incidents was shared across the practice team.

  • When we inspected the practice in 2016 the practice was not able to demonstrate that risks relating to legionella and recruitment of locum GPs were managed effectively. At this follow up inspection, the practice was able to demonstrate risks to patients were assessed and well managed. This included risks related to legionella and the use of locum GPs.

  • At our previous inspection the practice’s uptake for the cervical screening programme was lower than the local Clinical Commissioning Group (CCG) and national averages. We saw that there was a system in place to remind eligible patients to attend for their screening. However, at this inspection we saw that although the provider had been calling patients who did not attend the uptake for cervical screening had not improved.

  • Previously we saw that the practice had identified 15 patients as carers (0.9% of the practice list). At this inspection we saw that there was a slight improvement as 18 (1.1%) carers had been identified.

  • When we inspected the practice in June 2016 we identified that the practice governance processes were not effective to ensure feedback from patient surveys were actioned. During this follow up inspection we saw that the practice had taken action to improve in most areas we had previously identified as requiring improvement.

  • The practice was open between 9.30am and 6pm Monday to Friday. Results from the national GP patient survey showed that patients’ satisfaction with the practice’s opening hours was below local and national averages. Existing staff were unable to commit to earlier opening hours and the provider was in negotiation with potential new providers. Therefore, the provider decided not to employ any new staff to make it easier for a new provider to take over.

  • There was a complaints leaflet available which laid out the procedure and advised how patients could make a complaint. The complaints process was displayed in the reception area so that patients could be made aware of the process.

  • During our previous inspection in June 2016 we saw that the practice had carried out a patient satisfaction survey. However, there was no evidence that all relevant feedback had been actioned or considered. During this follow up inspection we saw that the practice had responded.

However, there were also areas of practice where the provider needs to make further improvements.

Importantly, the provider must:

  • Use feedback to drive improvements in the service in relation to opening hours.

In addition the provider should:

  • Continue exploring and implementing effective processes aimed at increasing the uptake of cervical cytology.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Uday Abhyankar’s practice on 30 June 2016. Overall the practice is rated as requires improvement.

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

  • There was an effective system in place for reporting and recording significant events. However, evidence we looked at showed that learning was not always shared across the practice team.
  • Most risks to patients were assessed and well managed. However, some risks such as those related to legionella and locum GP recruitment were not well 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.
  • The practice had not received any formal complaints in the last 24 months but a patient we spoke with confirmed that the practice had taken action following a verbal complaint they had made.
  • 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 team were small but there was a leadership structure and staff felt supported by management. The practice sought feedback from patients but was not clear from the evidence provided that it acted upon them.

  • There were arrangements to identify and manage risks but they were not comprehensive. The practice had a defibrillator and was aware that it had not been working for the past three years but no action had been taken ensure it was in good working order.

The areas where the provider must make improvement are:

  • Introduce robust systems or processes to mitigate the risks relating to the health, safety and welfare of service users. This includes the management of risks from legionella and ensuring appropriate arrangement for business continuity.

  • Recruitment procedures must be established and operated effectively to ensure appropriate background checks and to ensure indemnity is in place for locum GP.

The areas where the provider should make improvement are:

  • Ensure learning from all incidents are shared widely with staff and relevant stakeholders.

  • Review systems to improve achievement for cervical cytology.

  • Review systems to increase the number of carers registered at the practice so that they could be signposted for further support where appropriate.

  • Repeat prescribing process should be reviewed to ensure relevant tests were carried out before processing prescription.

  • Ensure all findings from patient surveys are actioned or considered.

  • Opening hours should be reviewed as national patient survey data shows achievement for opening times are below local and national averages.

  • Display complaints process and document verbal complaints to share learning.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 April 2014

During an inspection looking at part of the service

At our previous inspection on 28 June 2013 we found that the provider did not have a robust arrangement to deal with any foreseeable medical emergencies. We found that there were no formal recruitment systems in place. This meant that patients were not fully protected from risks of unsuitable people being employed. We also found that the provider did not have a robust system in place for monitoring the quality of service provision. The provider sent us an action plan to state how these concerns would be addressed. We looked to see what improvements had been made.

During this inspection the provider (regular GP) and the practice manager were away on leave. We met and spoke with a locum GP who was covering in the providers absence. We also spoke with two reception staff. One of the reception staff also worked as a healthcare assistant (HCA).

We saw that improvements had been made in relation to emergency medication. This meant that the practice would be able to respond to a medical emergency appropriately.

We found that appropriate recruitment procedures were in place so that staff were suitable to work at the practice.

Procedures were now in place to manage and learn from incidents to improve the service provided.

28 June 2013

During a routine inspection

We spoke with four patients who told us they were happy with the level of care they had received. We observed staff interacting positively with patients. All the patients told us access to the doctor was never a problem, and they were usually seen either the same day or the next. One patient told us 'No problem getting appointment, I was able to make an advance appointment'. All the patients told us they were listened to and felt their care was personalised and met their needs.

There was evidence that the provider had made arrangements to ensure the surgery building was being maintained appropriately so that it was safe and appropriate for people.

We found that there were no formal recruitment systems in place. This meant that patients were not fully protected from risks of unsuitable people being employed.

The provider did not have a robust system in place for monitoring the quality of service provision. The provider did not demonstrate learning from accidents and incidents.

Patients we spoke with told us they were happy with the level of care they had