Archived: Fiveways Health Centre

Updated 16 July 2019

Fiveways Health Centre is located in Ladywood Middleway, Birmingham. The surgery operates out of purpose-built premises.

At the time of the inspection there were no patients being seen at Fiveways Health Centre. The practice is not currently part of any wider network of GP practices, patients under care taking agreement will be included in the arrangements made by the caretaking practice. The practice provides NHS services through a General Medical Services (GMS) contract to 4,000 patients. The practice is part of Sandwell & West Birmingham Clinical Commissioning Group (CCG).

The practice is registered with the CQC to carry out the following regulated activities - diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury. The patient profile for the practice has a lower than national average percentage of patients aged over 65 years, currently 8% of its registered population is in this age group in comparison to the national average of 17%. The locality has a higher than average deprivation level. Based on data available from Public Health England, Five Ways Health Centre is located in an area with high levels of deprivation compared to the national average. For example, the practice is ranked one out of 10, with 10 being the least deprived. The practice population is made up of 59% of people from black and minority ethnic (BME) groups. Patients currently registered with the practice are being cared for by a caretaking practice and the practice currently provides no services.

The practice’s clinical team has one male GP. The practice is currently in the process of recruiting a practice nurse and a female GP. The non-clinical team consists of an acting practice manager, a small support manager and a small team of reception/administration staff. The practice has not been delivering patient care since 8 June 2018, but when the practice is open the hours are between 8am to 8pm Mondays to Fridays and 10am to 12 midday Saturday and Sunday. Appointments are planned to be offered from 9.30am to 12.30pm and 4pm to 6.30pm Monday to Friday. Extended hours appointments are available Monday to Friday between 6.30pm to 7pm and 10am to 11.30am Saturday and Sunday. Telephone consultations are available if patients requested them; home visits are also available for patients who are unable to attend the surgery if they lived within the practice boundaries. When the practice is closed, out of hours service is provided by NHS 111 service.

Updated 16 July 2019

We carried out an announced focused inspection at Fiveways Health Centre on 9 May 2019 to establish if the practice had carried out their plan to meet the legal requirements in relation to the breaches of the Health and Social Care Act 2008 identified at previous inspections.

The breaches of regulations identified at previous inspections were as follows:

A comprehensive inspection was carried out on 9 January 2018. Significant failings were identified in the care and treatment of patients and the practice was rated as inadequate overall and placed into special measures. Under Section 29 of the Health and Social Care Act 2008 two warning notices were issued in respect of the following regulated activities: Treatment of Disease, Disorder or Injury and Diagnostic and Screening Procedures. The provider was required to submit an action plan of planned improvements to mitigate the risks identified. The provider was required to provide the Care Quality Commission with specified information and documentation under Section 64 of the Health and Social Care Act 2008.

A focused unannounced inspection was carried out on 6 June 2018 to review the actions the practice had taken and to check whether the provider had implemented their action plan. Following this inspection, we found further significant failings in the management of patient care and treatment and 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 four months was imposed on the registration of the provider and registered manager in respect of the following regulated activities: Diagnostic and screening procedures, Treatment of disease, disorder or injury, Family planning, Maternity and midwifery services and Surgical procedures. The suspension took effect from Friday 8 June 2018 until 8 October 2018.

A focused announced inspection was carried out on the 20 and 25 September 2018 to review the actions the practice had taken during the suspension to ensure all failings and associated risks had been mitigated and processes had been implemented for the safe care and management of patients. Findings from the inspection showed the provider had failed to address the issues we had highlighted as being necessary for the suspension to be lifted. In addition, we found additional failings that would or may have exposed patients to the risk of harm. An extended suspension took effect from Monday 8 October 2018 for a period of 28 days.

A focused inspection on 8 November 2018 showed some improvements had been made, but failings in the management of safety alerts and patients with safeguarding concerns still had not been addressed effectively to ensure the safe care and treatment of patients. The practice remains in special measures and CQC continue to follow the enforcement pathway.

You can read the report from the previous inspections; by selecting the ‘all reports’ link for Fiveways Health Centre on our website at www.cqc.org.uk.

At this inspection, 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 rating remains inadequate overall.

We found that:

• The practice had implemented systems to ensure all safety alerts were received and actioned appropriately, however the lead for safety alerts was not proficient in navigating the system in order to find specific alerts.
• A review of the clinical registers had taken place to ensure they were up to date and reflected the current needs of the patients. However the lead for safeguarding had not reviewed the records of children on the cause for concern safeguarding register.
• The practice had commissioned the services of a consultancy agency to support them in the implementation of governance processes and to support the acting practice manager in their development.
• A comprehensive range of risk assessments had been implemented to monitor the premises and mitigate risk. However, plans for the registered manager to monitor this going forward had not been developed, nor had the appropriate training been completed. Following the inspection, evidence was received to demonstrate the registered manager had completed a range of training modules.
• A review of practice policies and processes had been completed to ensure they were effective and appropriate to support staff in their roles.
• The practice was unable to demonstrate that appropriate training had been completed or that the process for monitoring training was effective. Since the inspection we have received evidence to confirm that all staff have completed training relevant to their role.

We rated the practice as inadequate for providing safe services because:

• During inspection we found inconsistencies in the information that was provided to the inspection team. We were unable to establish whether recruitment had been safe for a new member of staff.
• The clinical lead was unable to demonstrate knowledge of the latest NICE guidelines to be issued.
• The lead for safety alerts was not proficient in navigating the system in order to find specific alerts.
• The provider did not demonstrate a proactive approach to stakeholder engagement in relation to professionals involved in safeguarding children and vulnerable adults. Records of children on the cause for concern safeguarding register had not been reviewed.

We rated the practice as inadequate for providing well led services because:

• The provider understood the challenges for the practice; but had no formalised plans in place to ensure sustainability was maintained.
• The practice was unable to demonstrate they had considered clinical capacity in both the short and long term. There were no plans in place to ensure the practice had the appropriate levels of staffing to support patient care.
• We were told that the registered manager would have overall responsibility for ensuring systems and processes were being managed appropriately, this included risk management. We found that there were no governance arrangements or associated training in place to support this.
• The provider did not demonstrate that effective stakeholder engagement was in place.

The provider continued to be in breach of Regulation 17 HSCA (RA) Regulations 2014 Good governance

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