The Care Quality Commission
  • Doctor
  • GP practice

Pak Health Centre - R Bhatti

Overall: Requires improvement read more about inspection ratings

Pak Health Centre, 38 Alum Rock Road, Birmingham, West Midlands, B8 1JA (0121) 327 3926

Provided and run by:
Pak Health Centre - R Bhatti

All Inspections

16 January 2023

During a routine inspection

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

24 May 2022

During an inspection looking at part of the service

We carried out an announced inspection at Pak Health Centre – R Bhatti between 17 May 2022 to 24 May 2022. Overall, the practice is rated as Inadequate.

The ratings for each key question, are as follows:

Safe - Inadequate

Effective – Inadequate

Caring – Good (carried over from previous inspection)

Responsive – Good (carried over from previous inspection)

Well-led - Inadequate

Following our previous inspection on 11 September 2019, the practice was rated Good overall and for all key questions except the effective key question which was rated requires improvement:

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:

This inspection was a focused inspection to follow up on identified risks.

How we carried out the inspection:

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/reviews 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 Inadequate overall

We found that:

  • There were weaknesses in the governance arrangements to keep patients safe and protected from avoidable harm and promote the delivery of high-quality person centred care.
  • The practice had been without managerial support for two years and whilst a manager had now been appointed there was significant work for them to implement systems and processes to support staff that had been absent for some time.
  • We found many of the systems and process to support good governance had only recently been initiated. For example, infection prevention and control arrangements, health and safety risk assessments.
  • We found gaps in governance arrangements in areas such as fire safety, management of patient safety alerts, monitoring of professional registration, staff training and appraisals.
  • There was limited learning from incidents, which included only non-clinical incidents.
  • Our clinical searches found limited documentation of medicine reviews, an inconsistent approach to managing pathology reports undermining the effective oversight and management of results and limited evidence that patients wishes at end of life were routinely discussed, formally recorded and easily accessed when needed.
  • There was little evidence of quality improvement initiatives in relation to clinical care and recommendations made from external reports and risk assessments were not always fully acted upon.
  • Our clinical searches found some areas where there had been appropriate follow up for patients on high risk medicines. However, during the inspection pharmacy support had been withdrawn from the practice due to a dispute with the primary care network.
  • Our review of long term condition management found mixed results with appropriate follow up seen for some conditions while others lacked timely follow up.
  • There was a low uptake of child immunisations and cancer screening programmes compared to national targets and averages.
  • The practice’s vision and strategy were hampered by the withdrawal of support from the primary care network due to a breakdown in relationships.

We found breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • 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).

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 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.

11 September 2019

During a routine inspection

We carried out an announced comprehensive inspection at Dr R Bhatti, Pak Health Centre on 11 September 2019 as part of our inspection programme.

The practice was rated as requires improvement for all key questions and requires improvement overall at the previous inspection in April 2018. You can read the report from our last comprehensive inspection on 4 April 2018; by selecting the ‘all reports’ link for Pak Health Centre – R Bhatti on our website at www.cqc.org.uk.

This report covers our findings in relation to improvements made since our last inspection and any additional improvements we found at this inspection. The report covers our findings in relation to all five key questions and six population groups.

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 good overall and good for all population groups except for families, children and young people and working age people (including those recently retired and students) which were rated as requires improvement.

We rated the practice as requires improvement for providing effective services for families, children and young people and working age people (including those recently retired and students) because:

We found that:

  • Childhood immunisation rates were lower than local and national averages.
  • Cancer screening targets were lower than local and national averages.

We rated the practice as good for providing safe, caring, responsive and well led services because:

We found that:

  • The practice had completed an infection control audit and had an action plan in place. Evidence provided showed the practice was acting on the identified concerns.
  • We found the majority of staff had the appropriate vaccinations relevant to their role, however the practice was unable to demonstrate that some of the clinical staff were up to date.
  • Since the previous inspection the practice had implemented a weekly test of the water supply to monitor temperatures as part of their actions to safeguard patients from legionella.
  • The practice had reviewed its safety procedures to ensure where COSHH items were stored they were kept in secured locked areas.
  • A training matrix had been implemented to monitor all staff were up to date with training relevant to their role.
  • Since the previous inspection the practice had implemented systems to ensure prescription stationery was kept secure. This included a log of prescriptions being used.
  • The practice had produced questionnaires in a range of languages to ensure all patients at the practice had the opportunity to share their views on the services provided. Following the inspection we received further evidence to support the practice were monitoring patient feedback on access which demonstrated positive results.
  • The practice had effective systems in place to monitor patients on high risk medicines. We found four patients on high risk medicines, on reviewing each patient record we found appropriate reviews and monitoring was in place and alerts were on patients’ records to ensure all staff were aware patients were on this specific group of medicines.
  • New staff had been employed since the previous inspection, including nursing and administration staff to manage staff absence and to offer more appointment availability.
  • The practice had reviewed their system for the monitoring of incidents, significant events and complaints. They had implemented a system to monitor trends and analyse information to minimise future risk and improve patient satisfaction.
  • The complaints procedures had been strengthened to ensure all information followed the recommended national guidance.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to encourage patients to attend cancer screening and child immunisations to improve uptake.
  • Monitor staff immunisation status to ensure records are up to date.

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

27 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We completed a comprehensive inspection at Pak Health Centre - R Bhatti on 27 March 2015. The overall rating for the practice is good. We found the practice to be good in the safe, effective, caring, responsive and well-led domains.

Our key findings were as follows:

  • Systems were in place to ensure that all staff had access to relevant national patient safety alerts. Staff worked together as a team to ensure they provided safe, co-ordinated patient care.
  • Infection prevention and control systems were well managed and staff had received appropriate training.
  • Staff were friendly, caring and respected patient confidentiality. Patients we spoke with said that all staff were compassionate, listened to what they had to say and treated them with respect. We observed that staff at the reception desk maintained patient’s confidentiality.
  • There was a register of all vulnerable patients who were reviewed regularly. Patients we spoke with told us they were satisfied with the care they received and their medicines were regularly reviewed. Information and feedback from patients was used to deliver service improvement.
  • The practice had a clear vision to deliver high quality care and promote good outcomes for patients. This was evident when speaking with staff and patients during our inspection. There was a clear leadership structure with named staff in lead roles.

In addition the provider should:

  • Commence full cycle clinical audits to demonstrate improvements in patient care and treatments are an on-going process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice