Birmingham health centre rated inadequate - here’s why

A Birmingham health centre has been rated inadequate after failing to provide evidence that terminally ill patients were consulted on their end-of-life wishes. In a damning report Pak Health Centre, also known as Pak Pharmacy, on Alum Rock Road, received the lowest rating in 4 out of 6 categories.

This marks a serious decline in standards since its last inspection in September 2019 when the service was rated good overall. The Care and Quality commission said: “There was a lack of evidence that patients’ wishes were discussed as part of end-of-life care and end-of-life discussions took place to ensure patients’ wishes were respected.”

The family-based practice consisting of a father/ daughter GP service and provides access to health consultation for around 5,000 patients. During an inspection in May 2022, the CQC found that patients were not being kept safe from avoidable harm and a lack of documentation of medicine reviews.

The investigation also found one patient taking heart medication had failed to receive a check-up for nearly two years. The CQC said: “In one review a patient taking beta-blockers (a medicine used to slow the heart) had not had their blood pressure or heart rate checked since November 2020. This potentially placed patients at risk of harm as they may not be aware of potential side effects or the importance of compliance with their medicines.

“We also reviewed records for a sample of patients on disease-modifying antirheumatic drugs (DMARDs) and other high-risk medicines that require regular blood tests and monitoring due to the risk of significant adverse side effects. The practice had seven patients on a particular DMARD, when we looked at the records for five of those patients, four of the records had no day of the week recorded to take the medicine in line with guidance to reduce the risk of potential overdose.”

What else did the report show?

The report also found the centre was seriously unprepared in the event of a fire. The CQC said: “A fire risk assessment had been undertaken however, actions had yet to be fully completed. The practice had undertaken a fire drill during the inspection process however before this there had been no fire drills or fire alarm testing since 2019.

“The practice manager was the fire marshal but only worked two days per week. The practice has also been without managerial support for two years and whilst a manager has now been appointed there is significant work for them to implement systems and processes to support staff that have been absent for some time.”

In the areas of whether the services were caring and responsive, inspectors said they were good. Officers continued: “The practice manager had been in place approximately six months and was working to improve the administration of the service and implement systems and policies that had been absent prior to their recruitment.

“The practice had adapted how it offered appointments to meet the needs of patients during the pandemic. The practice actively monitored the quality of access and made improvements in response to findings”

The service has now been placed in special measures. Services placed in special measures will be inspected again within six months and if insufficient improvements have been made the CQC will take action which could lead to cancelling their registration. Pak Health Centre declined to comment.

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