Dr Mohan S Saini Also known as Soho Medical Services

Updated 30 April 2020

Dr Mohan S Saini’s practice is located in the Soho Road Primary Care Centre in Handsworth, Birmingham which they share with four other GP practices. The surgery has good transport links and there is a pharmacy located nearby.

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

The practice sits within Sandwell and West Birmingham Clinical Commissioning Group (CCG) and provides services to 3,350 patients under the terms of a General Medical Services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community. The practice is part of the I3 Primary Care Network (PCN). PCNs are groups of practices working together to improve and develop services locally.

The practice has two partners (male and female) supported by a long-term locum GP (male), a practice nurse and a health care assistant. Other practice staffing consists of a practice manager, a senior administrator and a team of three reception/administrative staff.

The practice opening times are Monday and Friday 8am to 6.30pm and Tuesday, Wednesday and Thursday 8am to 7pm. Patients can also access extended access appointments at other local practices in the evening between 6.30pm and 8pm and at weekends 9am to 1pm on a Saturday and 9am to 12 pm. During the out of hours period, patients can access primary medical services through the NHS 11 telephone number. The out of hours provider for the practice is Birmingham and District General Emergency Room (BADGER).

The area served by the practice has high levels of deprivation. Information published by Public Health England rates the level of deprivation within the practice population as one on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. The practice population age distribution is younger than CCG and national averages. The National General Practice Profile describes the practice ethnicity as being 52% Asian, 20% Black, 19% white, 5% mixed and 4% other non-white ethnicities. Male life expectancy is 76 years compared to the national average of 79 years. Female life expectancy is 83 years compared to the national average of 83 years.

Updated 30 April 2020

We carried out an announced comprehensive inspection at Dr Mohan S Saini on 4 March 2020 as part of our inspection programme.

The practice was previously inspected on the 22 July 2019 and received a rating of inadequate overall and was placed into special measures. The practice was issued warning notices for breaches in the Health and Social Care Act (Regulated Activities) Regulations 2014, regulation 12 Safe care and treatment and regulation 13 Safeguarding Service Users form abuse and improper treatment. We also issued requirement notices for breaches in regulation 17 Good governance and regulation 16 Receiving and acting on complaints. We undertook a follow up inspection on 14 November 2019 to check progress against the warning notices. At this inspection we followed up on breaches of regulations identified at the inspection in July 2019.

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.

We rated the practice as good overall and good in all population groups; except for working age people which we rated as requires improvement.

• The practice had made significant improvements in response to our previous inspection in July 2019. The practice demonstrated a commitment to delivering high quality care, person-centred care and had been proactive in undertaking service improvement.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm. The practice had made significant improvements in safeguarding arrangements and medicines management. They were able to demonstrate a proactive approach to help keep patients safe from harm.
• The practice was able to demonstrate improvements in safety systems and processes including recruitment, management of risks and learning form incidents.
• Patients received effective care and treatment that met their needs. The practice had undertaken a significant range of quality improvement activity to ensure patients care and treatment needs were being met.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice  was significantly below targets for the uptake of cervical cancer screening.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The practice had made improvements in the management of complaints to ensure both verbal and written complaints were recorded to support learning and improvement.

We rated the practice as outstanding for the population group: people whose circumstances may make them vulnerable.

• The practice was able to demonstrate how their proactive approach to safeguarding was enabling them to more easily identify and safeguard patients who were at risk from harm. A system had been introduced to routinely collect information about a patient’s country of birth which enabled them to identify those at increased risk of Female Genital Mutilation (FGM). The practice had an 85% completion rate for this information and system alerts were installed to flag patients from high risk countries. This enabled clinical staff to ask questions to help safeguard patients. The practice had identified 30 patients at risk and was able to demonstrate how they had used this system to work with other agencies to protect those patients at risk of FGM.

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

• All staff to undertake safeguarding training to a level appropriate to their roles in line with guidance.
• Improve systems for the ongoing monitoring of staff registration with their professional bodies.
• Include risks relating to storage of oxygen as part of overall risk assessments.
• Improve the formal documentation of patient meetings for future reference of discussions and ensuring actions identified are taken forward.
• Continue with efforts to improve uptake of childhood immunisations and cervical screening.

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

Updated 30 April 2020

Updated 30 April 2020

Updated 30 April 2020

Updated 30 April 2020

Updated 30 April 2020

Updated 30 April 2020