Bordesley Green Surgery

We carried out an announced comprehensive inspection at Bordesley Green Surgery on 22 June 2023. Overall, the practice is rated as good.

Safe – Good

Effective – Requires Improvement

Caring – Good

Responsive – Good

Well-led – Good

Following our previous inspection on 24 November 2022, the practice was rated inadequate overall but good for providing caring services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bordesley Green Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

The focus of inspection included:

• A review of all key questions
• Follow up of breaches of regulations identified in 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 short site visit.
• Speaking with patients and members of the practice’s patient participation group (PPG).

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 provided care in a way that mainly kept patients safe and protected them from avoidable harm.
• The practice management team had carried out a review of its safeguarding processes and ensured they were more effective. Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
• The practice had a system for recording and disseminating actions carried out as a result of significant events.
• The practice had taken appropriate action to support and protect patients identified as at risk from harm.
• Our clinical searches found appropriate monitoring and management of patients on high risk medicines and for long term conditions was mostly in place. We found some areas that were not completed following clinical reviews which had the potential to be of concern if not identified. For example, not all patients were issued with steroid cards and there was a delay in completing blood tests to confirm diabetes diagnosis for some patients.
• Changes had been made to the practice triage systems, which made the process more effective.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had management oversight of staff qualifications and training.
• Staff were clear and knowledgeable about their lead roles and responsibilities.
• Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
• The practice had reviewed and implemented systems to address patients’ concerns about access to the practice for timely care and treatment.
• There continued to be a poor uptake by patients of preventative treatments and screening procedures. Practice staff were proactive in their attempts to increase uptake through education, opportunistic screening and working with other organisations.
• There were 70 patients registered as carers at the practice. This represented approximately 2.5% of the practice population.
• The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centered care.

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

• Continue to promote, monitor and explore ways to improve the uptake of childhood immunisations and cervical screening.
• Introduce systems to review and monitor the impact of any actions put in place to improve the uptake of preventative treatments and screening.
• Continue to monitor guidance, including that Medicines and Healthcare products Regulatory Agency (MHRA) alerts are reviewed, followed and recorded for patients prescribed high risk medicines.
• Continue to review, monitor and improve patient access to the practice.
• Review the completeness of patient clinical care and medicine reviews.

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

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 Health Care