The Care Quality Commission
  • Doctor
  • GP practice

Great Barr Medical Centre

Overall: Inadequate read more about inspection ratings

379 Queslett Road, Birmingham, B43 7HB

Provided and run by:
Great Barr Medical Centre

All Inspections

26 April 2023 and 27 April 2023

During a routine inspection

We carried out an unannounced comprehensive inspection at Great Barr Medical Centre on 26 April 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring - requires improvement

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 14 June 2022, the practice was rated good for safe, caring and well led key questions, requires improvement for effective and responsive key questions and rated as requires improvement overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Great Barr Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns reported to us.

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:

  • 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 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 found that:

  • The practice did not have appropriate systems in place for the safe management of medicines. This included an ineffective system for the management of safety alerts, as actions had not been taken to ensure patients were informed of potential risks with certain medicines.
  • Patients on high risk medicines were not being monitored or reviewed regularly. We found examples of medicine reviews being coded as completed, however there was no evidence to demonstrate that patients’ medicines had been reviewed appropriately.
  • We found patients had not had health conditions clinically coded appropriately and the summary of their medical problems was not up to date.
  • We found safeguarding registers had not been maintained appropriately and the information held was inaccurate.
  • The practice were unable to demonstrate effective clinical supervision of staff carrying out clinical roles to ensure they were acting within their competencies. We found significant concerns in the prescribing of medicines and the lack of information recorded in patients’ consultations and missed referrals to other services.
  • Clinical registers were not up to date and were ineffective. This demonstrated a lack of clinical management of patients’ health conditions.
  • We found delays in the actioning of clinical referrals and urgent tasks. The provider was unable to demonstrate effective processes were in place to monitor that systems were being followed.
  • We found no system in place for the acknowledgement and investigation of patient complaints.
  • The provider was unable to demonstrate that incidents that affect the health, safety and welfare of people using services were reported internally and to relevant external authorities. We found no evidence to demonstrate that incidents had been shared with staff to promote learning.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective. The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • The practice was unable to demonstrate effective leadership. The lack of adequate processes were putting patients at risk and the provider did not have the capability to lead effectively and drive improvement.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The provider should:

  • Implement a process to encourage patients to attend for immunisations and cervical screening.
  • Explore ways of improving numbers of carers on the register.

Due to the significant failings we identified in the management of patient care and treatment on the unannounced inspection on 26 April 2023 urgent action was taken to protect the safety and welfare of people using this service. Under Section 31 of the Health and Social Care Act 2008 a temporary suspension of six months was imposed on the registration of the provider in respect of the following activities Diagnostic and screening procedures, Treatment of disease, disorder or injury, Family planning, Maternity and midwifery services and Surgical procedure at Great Barr Medical Centre. This notice of urgent suspension of the provider was imposed due to the seriousness of the lack of appropriate care and treatment found and because we believe that a person will or may be exposed to the risk of harm if we did not take this action. The suspension took effect from Wednesday 3 May 2023.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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

14 June 2022

During a routine inspection

We carried out an announced inspection at Great Barr Medical Centre on 14 June 2022. Overall, the practice is rated as Requires improvement.

Safe - Good.

Effective - Requires improvement.

Caring - Good.

Responsive – Requires improvement.

Well-led – Good.

Following our previous inspection on 6 December 2021 the practice was rated Inadequate overall and for safe, effective and well-led key questions but Good for providing caring services and Requires improvement for providing responsive services. The practice was placed into special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Great Barr Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection, carried out within six months of the service being placed into special measures to see if the provider had made the necessary improvements to provide safe and effective care.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider.

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 Requires improvement overall.

We found that:

  • The provider had made improvements since the previous inspection in December 2021 to become compliant with regulations.
  • The provider had reviewed their governance arrangements and implemented new governance processes and structures to enable them to deliver safe care.
  • The provider was able to demonstrate that all staff had the skills, knowledge and experience to carry out their roles and that staff received appropriate clinical supervision.
  • The provider had reviewed its processes to ensure the practice held appropriate emergency medicines.
  • Despite the improvements made, the provider could not demonstrate that all patients received effective care and treatment that met their needs. For example, the practice had not achieved the minimum uptake targets for cervical cancer screening or children’s immunisations. Following the inspection, the provider submitted unverified data to show uptake had improved since March 2022, however they could not assure us that improvements had been sustained.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The provider had reviewed and improved systems to manage complaints and demonstrated complaints had been responded to appropriately.
  • The provider had acted to improve telephone and appointment access, however, at the time of the inspection, could not demonstrate that patient satisfaction had improved significantly with regards to access.
  • The provider demonstrated they had the necessary skills and were capable of leading and managing the practice to promote the delivery of high-quality, person-centred care.

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

  • Continue to monitor that governance processes are effective and make further improvements as needed.
  • Continue to respond to patient feedback and explore alternative ways to improve telephone and appointment access, including for those patients with more urgent needs.
  • Continue to improve uptake with childhood immunisations and cervical cancer screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22 March 2022

During an inspection looking at part of the service

We carried out an announced inspection at Great Barr Medical Centre on 22 March 2022. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements set out in warning notices we issued to the provider in relation to regulation 12 Safe care and treatment and regulation 17 Good governance.

At the last inspection in December 2021 we rated the practice as Inadequate overall. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Great Barr Medical Centre on our website at www.cqc.org.uk

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider after the inspection 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 found that:

  • The provider had complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
  • We found that patients who were treated with medicines that required additional monitoring had received the appropriate blood tests and follow up in line with safe prescribing guidelines.
  • The practice had reviewed and improved systems to manage patient safety alerts. Records we checked showed that alerts were actioned appropriately.
  • The practice had reviewed and improved their systems to manage patients with long term conditions. Records we reviewed showed patients had appropriate care plans in place.
  • The practice had reviewed and improved processes to effectively manage recruitment files and staff training information.
  • The provider had reviewed systems to ensure relevant premises risk assessments were being completed and necessary actions being taken.
  • The provider was able to demonstrate that all staff had the skills, knowledge and experience to carry out their roles and they had implemented a system to provide clinical supervision to non-medical prescribers.
  • The provider had reviewed it’s processes to ensure the practice held appropriate emergency medicines.
  • The provider had reviewed and improved systems to manage complaints and demonstrated complaints had been responded to appropriately.
  • The provider had reviewed governance arrangements and implemented new governance processes and structures to enable them to deliver safe and effective care. Where we identified that processes had not been fully embedded, we discussed these with the provider during the inspection. The provider acknowledged further improvements were needed.

Whilst we found no breaches in regulation the provider should:

  • Continue to review, improve and embed newly implemented systems and processes. For example, systems to manage staff information, high risk medicines and the coding of records.

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

06 December 2021

During a routine inspection

We carried out an announced inspection at Great Barr Medical Centre on 6 December 2021. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective – Inadequate

Caring - Good

Responsive - Requires Improvement

Well-led - Inadequate

Why we carried out this inspection

The practice has not been inspected before. This inspection was carried out to provide a rating for the practice. The inspection was also carried out in response to concerns we had received about appointment access and GP availability.

This inspection was a comprehensive inspection and we included all five key questions: safe, effective, caring, responsive and well-led.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using telephone and video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider after the inspection 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 Inadequate overall.

We found that:

  • The practice did not have effective systems and processes to keep patients safe.
  • There was no oversight of staff training and no training information available for non-clinical staff.
  • There was no evidence that staff had completed the relevant infection prevention and control training for their role or that non-clinical staff had completed safeguarding training that was relevant to their role.
  • There was no oversight of risk assessments related to the premises and the practice could not provide evidence of health and safety risk assessments or a recent fire risk assessment.
  • The practice was not able to demonstrate that all staff had the skills, knowledge and experience to carry out their roles. The practice could not demonstrate that staff had received induction, regular reviews and appraisals or clinical supervision.
  • The practice had taken action to improve telephone and appointment access. This included installing a new telephone system and implementing a system that allowed them to monitor which patients needed an appointment after all the appointments had been taken for the day.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic and had re-started offering face to face appointments from March 2021.
  • The practice did not have effective systems to manage complaints and could not demonstrate that all complaints had been responded to appropriately.
  • The practice was unable to demonstrate effective leadership. The lack of adequate processes was putting patients at risk.
  • However, the provider responded appropriately to our concerns following the inspection, indicating the leadership team did have the capability to provide safe and effective care.

We found two breaches of regulations. The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

(Please see the specific details on action required at the end of this report).

The provider should:

  • Improve systems and processes to more effectively manage significant events.
  • Improve systems for arranging chaperones and interpreters.
  • Implement systems and processes to more effectively manage records awaiting summarising.
  • Continue to improve uptake with childhood immunisations and cancer screening.
  • Implement processes to engage with staff and patients so that learning can be shared, and quality of services provided can be improved further.
  • Continue to improve accessibility for all patients including those with a sensory impairment.

We identified breaches and as result of our inspection, a warning notice was issued under Section 29A of the Health and Social Act 2008 to the provider Great Barr Medical Centre in relation to the regulated activities: diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures. This was due to the ineffective systems in place for the management of risk, inadequate leadership to maintain appropriate governance processes and ensure staff had completed training relevant to their roles.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of Inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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