Background to this inspection
Updated
21 December 2022
Church Road Surgery is located in Birmingham at:
28 Church Road
Aston
Birmingham
B6 5UP
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury and surgical procedures.
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 4,447. This is part of a contract held with NHS England.
The practice is part of i3 Ladywood 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 37% Asian, with 36% White, 19% Black and 8% Mixed and Other.
The practice team consist of a single-handed GP, two salaried GP’s, a long-term GP locum, an advanced nurse practitioner, a part time learning disability nurse, a practice nurse and a health care assistant. Non-clinical staff include a practice manager, an operations manager and a team of administrative/reception staff.
The practice is open between 8am to 6.30pm Monday to Friday with extended access on Monday and Tuesday between 7.30am until 8am and 6.30pm and 7pm on Monday and Wednesday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
Improved access is provided locally through the primary care network, where late evening and weekend appointments are available during the week. The practice hosts appointments on Saturdays between 9am and 5pm across the PCN. Out of hours services are provided by Badger.
Updated
21 December 2022
We carried out an announced comprehensive inspection at Church Road Surgery on 17 November 2022. Overall, the practice is rated as good.
Safe - good
Effective - good
Caring - good
Responsive - good
Well-led - outstanding
Why we carried out this inspection
This inspection was a comprehensive inspection due to changes to the registration of the provider and includes the safe, effective, caring, responsive and well-led key questions.
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 have rated this practice as Good overall and outstanding in Well-led.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- There was a good working relationship with the Patient Participation Group (PPG), which supported the practice with patient interaction and improving service delivery.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Staff at all levels were encouraged to speak up and raise concerns.
- There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way which meets those needs, which was accessible and promoted equality.
- Services were developed with the full participation of those who use them, staff and external partners.
- Staff who worked at the practice were consistently positive about teamwork; being involved in decision making; and being supported to carry out their roles.
The practice is rated as outstanding in well-led because:
- The practice provided high quality care and treatment to patients which was driven by effective governance and leaders inspired staff to provide patients with the highest quality evidence-based primary care.
- There was a strong emphasis on learning, evaluation and impact and a willingness to try new ideas to benefit patients.
- The practice was innovative and used technology to demonstrably act on its vision by carrying out a number of quality improvement projects to meet the changing demands of the population.
- The provider participated in research projects and used internal audit and quality improvement programs to review and improve care and treatment. There was a focus on sharing the work of the practice locally and nationally as well as a shared commitment at all levels to learn from others.
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