Archived: Church Lane - Khan

Updated 5 October 2022

Church Lane - Khan is located in Birmingham at:

113 Church Lane

Stechford

Birmingham

West Midlands

B33 9EJ

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

During the inspection we saw there were changes to the partnership, the practice has been made aware that it must update their registration with CQC without delay to ensure it is accurate.

The practice is situated within the Birmingham and Solihull Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 3,300. This is part of a contract held with NHS England.

The practice is part of the Birmingham East Central Primary Care Network (PCN). A PCN is a wider network of GP practices that work together to address local priorities in patient care.

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 69% White, 16% Asian, 8% Black, 6% Mixed, and 1% Other.

The practice team consists of a principal GP (male) and salaried GP (female), a practice nurse and phlebotomist. The clinical team is supported by two locum Healthcare Assistants. Non-clinical staff include a practice Manager and a team of four administrative / reception staff.

The practice is open between 8.15am to 6pm Monday to Friday, with the exception of Thursdays when the practice closes at 1pm. On a Thursday afternoon telephones are answered and if a patient requires an urgent appointment this is covered by the on-call GP and if needed an appointment can be given at another health centre through local arrangements. Extended access appointments are available alternate Saturdays between 9am and 3pm. All GP appointments are triaged by a doctor who decides whether the patient needs to be seen face to face. Appointments with a nurse of healthcare assistant can be booked up to 7 days in advance. Appointments can be booked online or by telephone. When the practice is closed patients can access out of hours primary medical services via the NHS 111 telephone line.

Updated 5 October 2022

We carried out an announced focused inspection at Church Lane - Khan on 5 September 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are as follows:

Safe - requires improvement

Effective - requires improvement

Caring – good (rating carried over from previous inspection, May 2021)

Responsive – good (rating carried over from previous inspection, May 2021)

Well-led - requires improvement

Following our previous inspection on 11 May 2021, the practice was rated requires improvement overall and for the safe, effective and well-led key questions. The practice was rated good for the caring and responsive key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Church Lane - Khan on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this focussed inspection to follow up on breaches of regulation from a previous inspection.

The focus of the inspection included:

• Safe, Effective and Well-Led key questions
• Any breaches of regulations or ‘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 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 found that:

• The last 12 months had been a challenging time for the practice. In addition to the COVID-19 pandemic, the practice had several months without a practice manager, practice nurse and had a shortage of doctors. Many of the vacancies had now been filled and the practice was in a better position going forward to provide a high-quality service.
• The practice premises were in need of some refurbishment, this was currently on hold while the practice was working through future options for the premises.
• We found systems and processes for keeping patients safe were being reviewed following the appointment of the new practice manager. Some of the systems had recently been re-established after gaps in leadership and had yet to fully demonstrate their full effectiveness. For example, safeguarding arrangements, reporting and learning from incidents.
• Our review of clinical records found medicines were generally well managed, with the exception of some older safety alerts, which needed to be addressed.
• Patients received effective care and treatment that met their needs. Our review of clinical records demonstrated patients were receiving appropriate care and treatment. We saw some improvement in childhood immunisations and cervical screening uptake data although further work was required to ensure all indicators reached minimum standards.
• While the practice’s required staff training was well completed, the practice was not always able to demonstrate how it ensured the competence of all staff with extended or advanced roles.
• The practice was not able to demonstrate that it was proactive in ensuring patients wishes were recorded in relation to end of life care.
• Feedback from patients through the National GP Patient Survey and patients we spoke with showed patients were mostly happy with their experience of the service and access to care and treatment.
• The practice had considered and put in place plans to continue to improve the practice and now had the leadership to support this.
• While the practice had addressed some of the governance issues raised at our previous inspection, many of the systems and processes had been put in place relatively recently and needed embedding.

We found a breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

• Put in place arrangements for timely completion for summarising new patient notes.
• Update the fire risk policy so that it is practice specific and complete relevant risk assessments for patients who may not be able to evacuate the premises unaided in the event of a fire.
• Continue to strengthen governance arrangements, in particular around learning from incidents, quality improvement and establishing a freedom to speak up guardian.

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