Archived: Ejaz Medical Centre

Updated 13 March 2020

Druid Group is a provider of general medical services based at four sites. The main site is Ejaz Medical Centre, 276 Dudley Road, Birmingham, West midlands.

The three other branch sites are based at:

• Belchers Lane Surgery, 197 Belchers Lane, Birmingham, B9 5RT.
• Glebe Farm Road Surgery, 37-41 Glebe Farm Road, Birmingham, B33 9LY.
• Hobmoor Road Surgery, 533 Hobmoor Road, Birmingham, B25 8TH.

The practice had one patient list size of an approximate population of 11,300 patients. Whilst patients were able to access care at any site, the branch sites were approximately 45 minutes commute away from the main site. The overall rating for deprivation for all four sites is one out of ten in the deprivation decile (The Index of Multiple Deprivation 2015 is the official measure of relative deprivation for small areas (or neighbourhoods) in England. The Index of Multiple Deprivation ranks every small area in England from one (most deprived area) to 10 (least deprived area).

The service is run by three GP partners (all male) with a team of 11 other GPs (both male and female) on a salaried and locum basis. The practice employs one practice nurse for all sites. The practice had employed two pharmacist prescribers and three physician’s associates. Other members of the team include, four health care assistants (three trainees), a team of administration staff, a practice manager and an assistant practice manager.

The provider is registered with CQC to deliver the Regulated Activities:

• diagnostic and screening procedures
• family planning
• surgical procedures
• maternity and midwifery services
• treatment of disease, disorder or injury

The opening times are from 9am-12.30pm and 2pm-6pm Monday to Friday. The main site at Ejaz Medical centre and the branch site at Glebe Farm Road Surgery are closed on Wednesday afternoons. The branch sites at Belchers Lane Surgery and Hobmoor Road Surgery are closed on Thursday afternoons.

The practice has out of hours services and the telephone lines between the branch and main site are linked. When the practice is closed the telephone, lines are automatically diverted to the out of hours service provider (BADGER). The service also had an arrangement with the out of hours service to provide cover when it was closed during core hours.

Updated 13 March 2020

We carried out an announced comprehensive inspection at Ejaz Medical Centre on 9 December 2019 as part of our inspection programme.

At the last inspection in March 2019 we rated the practice as inadequate for providing safe, and well-led services because:

• The practice had not assessed and managed all risks such as those related to health and safety.
• The provider did not stock medicines for all emergency situations, a risk assessment was in place to support the decision making. However, the risk assessment was not comprehensive and did not provide a clear rationale for the decision and how a situation would be managed if it was required.
• The provider did not have an effective governance process to identify and mitigate all risks and to ensure a consistent approach to care delivery. For example, there was a lack of leadership oversight and an effective governance framework to monitor the quality and safety of the service provided.

We rated the practice as requires improvement for providing effective, caring and responsive services because:

• Cancer screening achievement including cervical cytology was below local and national averages.

• Staff treated patients with kindness, respect and compassion. However, feedback from the national GP patient survey showed some areas was below local and national averages and there was no evidence that the practice had reviewed and acted on the feedback.

• The practice was unable to demonstrate how they were responding to all findings of the national GP patient survey including patients overall experience at the practice and patient satisfaction with the appointments.

At this inspection, we found that the provider had satisfactorily addressed many of the areas identified previously. However, there were areas that required further improvement.

We based our judgement of the quality of care at this service is 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.
• Consider appropriateness of hand bells in comparison to a smoke detector or fire alarm to raise awareness in the event of serious fire.

We have rated the service as requires improvement overall including all population groups.

We rated the service requires improvement for providing effective, caring and responsive care.

We found that:

• The services achievement for cervical cytology was below local and national averages.
• Data provided by the practice post inspection for childhood immunisation demonstrated that they had achieved over 80% uptake but this was still below the minimum 90% target achievement rate.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. However, national patient survey feedback was below local and national averages.
• The practice was taking action to improve access to meet patient needs. However, national patient survey feedback was significantly below local and national averages and had deteriorated since our previous inspection. This did not suggest that patients always had access to timely care.

We rated the practice good for providing safe and well-led services.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The service was aware of the areas requiring further improvements such as childhood immunisations, cervical cytology and feedback on the national patient survey and was able to demonstrate actions being taken to achieve improvements.

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.

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

• Continue to respond to findings from the national patient survey to achieve improvements.

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

Updated 13 March 2020

Updated 13 March 2020

Updated 13 March 2020

Updated 13 March 2020

Updated 13 March 2020

Updated 13 March 2020