• Doctor
  • GP practice

Archived: Church Lane - Khan

Overall: Requires improvement read more about inspection ratings

113 Church Lane, Stechford, Birmingham, West Midlands, B33 9EJ 0845 071 1104

Provided and run by:
Church Lane - Khan

Important: The provider of this service changed. See new profile
Important: The provider of this service changed - see old profile

All Inspections

5 September 2022

During an inspection looking at part of the service

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

11 May 2021

During a routine inspection

We carried out an announced inspection at Church Lane – Khan on 11 May 2021. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Requires Improvement

Caring – Good

Responsive – Good

Well-led - Requires Improvement

Following our previous inspection on 22 August 2019, the practice was rated Requires Improvement overall and for all 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

This inspection was a comprehensive inspection to follow up on:

  • Safe, Effective, caring, responsive and Well-led key questions
  • Areas followed up included breaches of regulations and areas where the provider ‘should’ improve, identified in previous inspection
  • Ratings carried forward from previous inspection

How we carried out the inspection/review

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 Requires Improvement overall and requires improvement for all population groups.

We found that:

  • Actions pointed out during our previous inspection, regarding adding findings from the practice personal emergency evacuation plan to the fire risk assessment had not been carried out until following this inspection.
  • Safeguarding systems, processes and practices were developed, implemented, and communicated to staff. The management of incident was safe; and actions were taken to reduce the risk of recurrence.
  • The practice provided care in a way that kept most patients safe and protected them from avoidable harm. There were areas such as medicines management which was not carried out in line with national prescribing guidelines.
  • Quality Outcomes Indicators (QoF) data indicated that patients did not routinely received effective care and treatment that met their needs. The providers were aware of this and explained a range of factors such as COVID-19 pandemic and a period when they did not have a regular nursing team.
  • 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 which included the use of digital platforms such as video and telephone consultations. Patients could mainly access care and treatment in a timely way and the practice increased their phone lines to improve access.
  • Oversight of training needs, checking staff immunisation status during the recruitment process and documenting learning and outcomes following complaints needed further strengthening.
  • The practice carried out clinical audits as part of their quality improvement activities. However, the process did not demonstrate a continuous cycle which is continuously measured with improvements made after each audit cycle.
  • Assurance systems and arrangements for managing and responding to risks in a timely manner was not managed effectively. In particular, the practice did not operate effective governance arrangements to ensure information is being used systematically to monitor adoption of prescribing guidance and improvement of QoF performance.

We found the following breaches 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 breaches of regulations, we found the provider should:

  • Improve monitoring of staff completion of training updates identified by the provider as mandatory training.
  • Improve employee immunisation programme to include a review of staff’s immunisation needs.
  • Improve arrangements for identifying, recording, and managing risks including processes for responding to medical emergencies remains safe and effective.

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

22 August 2019

During a routine inspection

We carried out an announced comprehensive inspection of Church Lane – Khan’s practice (also known as The Surgery) on 22 August 2019.

The practice was last inspected in January 2019 and received a continued rating of Inadequate overall, therefore remaining in Special Measures since July 2018 when they were first inspected using our comprehensive inspection methodology.

At this inspection we followed up on breaches of regulations identified at a previous inspection in January 2018. You can read the reports from our last inspections by selecting the ‘all reports’ link for Church Lane Khan on our website at www.cqc.org.uk.

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.

Following this inspection we have rated this practice as Requires Improvement overall, the practice was rated as Requires Improvement for providing safe, effective, caring, responsive and well-led services; this included for effective care and responsive services to all of the six population groups.

We found that:

  • The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • Whilst the practice had systems, practices and processes to keep people safe and safeguarded from abuse, the governance of these systems were not fully effective in some areas.
  • The practice had systems for the appropriate and safe use of medicines, including medicines optimisation. However, during our inspection, we identified gaps in the practices system for the receipt of safety alerts as well as gaps in evidence to demonstrate that evidence-based guidance was followed in certain areas.
  • We found that performance was below target and below average in areas such as cancer screening and childhood immunisation uptake.
  • Although we noted some efforts to improve access, this was not evident in satisfaction rates for access to service and performance was less positive with regards to care. The evidence provided as part of the inspection did not provide assurance of plans to improve this area.
  • We noted a marked improvement following work undertaken to cleanse the practices patient record system, this was noted across clinical coding areas and clearer patient registers.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue with efforts to improve uptake of childhood immunisations and cancer screening overall.
  • Continue to explore further ways to improve patient satisfaction in response to feedback and below average satisfaction results.
  • Explore further ways to identify and capture carers to ensure their care and support needs are met.

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

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

16 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Church Lane Khan on 16 January 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 25 April 2018. You can read the report from our last inspection on by selecting the ‘all reports’ link for Church Lane Khan on our website at www.cqc.org.uk.

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 inadequate overall.

We rated the practice as inadequate for providing safe, effective and well-led services because:

  • The practice could not demonstrate that they had fully improved their recruitment and induction processes since our last inspection.
  • In areas, governance arrangements were ineffective and the practice did always not have clear and effective processes for managing risks and issues.
  • The practice did not always act on appropriate and accurate information. The practice did not demonstrate good governance with regards to their strategy and across specific coding issues where risks and areas for improvement had been identified.
  • Patient satisfaction was below average in areas such as for care and treatment provided and for access. Although we saw that some steps had been taken to improve, the evidence provided did not demonstrate that satisfaction rates had fully improved across all areas.
  • We noted in other areas that improvements had been made since our last inspection, this was reflected across sepsis awareness, child immunisation uptake, infection control and for the management of safety alerts and emergency medicines.
  • Discussions with staff highlighted a significant improvement in morale at the practice.

These areas affected all population groups so we rated all population groups as inadequate.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to identify carers to offer them support where needed
  • Continue to explore ways of improving uptake rates for cancer screening
  • Continue to explore ways of engaging with patients and improving satisfaction rates
  • Formally assess the need for a hearing loop to ensure that reasonable adjustments are made for patients where needed

This service was placed in special measures in July 2018. Insufficient improvements have been made such that there remains a rating of inadequate for providing safe, effective and well led services. Therefore we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

25 April 2018

During a routine inspection

This practice is rated as Inadequate overall. (Previous inspection February 2015 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Church Lane - Khan also known as The Surgery on 25 April 2018 as part of our inspection programme.

At this inspection we found:

  • That there were areas where the arrangements for identifying, recording, managing and mitigating risks were not effective.
  • A system to alert practice staff when individual patients who were subject to safeguarding measures had not been established, although there were systems for staff to report safeguard concerns. Following our inspection, the practice provided evidence to assure us that a system was in place to capture safeguarding concerns on patient records.
  • The practice sought to deliver care and treatment according to evidence- based guidelines. However, the practice was unable to demonstrate this in particular we found poor understanding and use of care plans and palliative care multi-disciplinary meeting templates were not completed to their entirety.
  • Staff demonstrated an awareness of the practice high exception reporting rates and, although they were operating a call and recall system for patients who required a review of their condition and treatment, we did not find evidence that a comprehensive plan was in place to address this issue.
  • 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 either above or comparable to local and national averages in most areas. Completed Care Quality Commission (CQC) comment cards were also positive about the services provided.
  • Completed CQC comment cards reported that patients found the appointment system easy to use and reported that they were able to access care when they needed it. However, there were some comments on NHS choices that were less positive about access. Practice staff were aware of the issues and were taking some action to improve access.
  • The practice governance arrangements were not effective and lacked the necessary clinical leadership or managerial oversight to ensure a systematic approach to sustain the quality of patient care and service delivery. There were areas where responsibilities had not been clearly defined and oversight of some processes was not effective. For example, the practice did not have clear oversight of safety alerts and the monitoring of actions to ensure compliance with safety recommendations.
  • Although the practice aimed for a culture of high-quality sustainable care, there were a number of areas where staff felt unsupported in their role and felt when internal concerns were raised these were not acted on.

The areas where the provider must make improvements are:

  • 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.

The areas where the provider should make improvements are:

  • Continue to encourage the uptake of childhood immunisations and national programmes such as cervical and breast cancer screening.
  • Carry out a risk assessment covering the choice and availability of medicines and equipment which may be needed in the case of a medical emergency
  • Review the arrangements for tracking blank prescriptions through the practice in line with national guidance.
  • Continue recalling patients and cleansing clinical records to reduce the practice exception reporting rates.
  • Use appropriate care planning tools for patients identified as being frail to evidence a planned approach to patients care needs.
  • Continue exploring and establishing effective methods to identify carers in order to provide further support where needed.
  • Continue exploring and following actions to improve patient satisfaction in areas such as access.
  • Continue reviewing non-clinical staffing levels to ensure appropriate cover during periods of low staffing levels.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

4 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection at Dr Khan, Church Lane practice on 4 February 2015.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because practice staff were caring and motivated.

Our key findings were as follows:

  • We found evidence that practice staff worked together to make on-going improvements for the benefit of patients.
  • We found that patients were treated with respect and their privacy was maintained. Patients informed us they were satisfied with the standards of care they received.
  • The practice was visibly clean and tidy. Annual in depth audits were carried out and resultant actions taken to protect patients from unnecessary infections when they visited the practice.
  • The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

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

In addition the provider should:

  • Record that verbal consent has been given prior to intimate examinations of patients and fully record the annual health checks carried out for patients with a learning disability.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice