Archived: OHP-Bartley Green Medical Practice

We carried out an announced comprehensive inspection at OHP-Bartley Green Medical Practice on 22 January 2020 as part of our inspection programme.

The practice was previously inspected on the 17 January 2019 and received a rating of requires improvement overall. At this inspection we followed up on breaches of regulations identified at a previous inspection on 17 January 2019.

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 rated the practice as requires improvement for providing safe, effective and well-led services and for the families children and young people and vulnerable people population groups because:

• The practice had systems and processes for keeping patients safe however we found areas where these were not always effectively managed or embedded.
• Although, we saw strong working relationships with the health visitng team the practice did not proactively manage the safeguarding register and not all staff had completed safeguarding training to a level relevant to their roles.
• The practice had taken action to monitor and strengthen recruitment processes, but further work was needed to ensure appropriate checks were consistently in place for all new staff.
• There were systems in place for recording and reviewing incidents however, the practice was not able to demonstrate wider learning was effectively shared across the team.
• Patient outcome and performance data was mostly in line with local and national averages with the exception of child immunisation and cervical screening uptake which was not meeting national minimum standards or targets. The practice was also unable to demonstrate how it supported patients with learning disabilities.
• We found the governance and leadership arrangements did not always fully support the delivery of high quality sustainable care.
  

We rated the practice as good for providing caring and responsive services and for the older people, people with long term conditions, working age people and people experiencing poor mental health (including dementia) population groups because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Feedback received through the CQC comment cards showed patients were positive about the service received.
• The practice had taken action to improve patient satisfaction in accessing services.

The areas where the provider must make improvements are:

• 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 areas where the provider should make improvements are:

• Continue to review progress in improving patient satisfaction in relation to access and take action as appropriate.
• Review action taken to improve the uptake of childhood immunisation and cervical screening and identify ways this may be further improved.
• Review areas of high exception reporting to identify any areas for improvement.
• Review how care and treatment for patients with a learning disability may be improved.

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

We carried out an announced comprehensive inspection at OHP – Bartley Green Medical practice on 17 January 2019 as part of our inspection programme.

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 rated the practice as Requires Improvement for providing safe services because:

• The practice demonstrated that systems were in place to ensure that patients were appropriately safeguarded. However, the practice was unable to demonstrate that safety systems and processes in place to manage risk throughout the practice were always fully effective, or being appropriately monitored. We found gaps where risks had not been considered, monitored and where actions identified had not been completed. Following the inspection, the practice demonstrated that it had taken action to address these concerns.

We rated the practice as Requires Improvement for providing responsive services because:

• Patients were not always satisfied with access to care and treatment, including telephone access and access to appointments. The practice demonstrated that they had and would continue to take actions to try and address this. However, they were unable to demonstrate that patient satisfaction had yet improved as a result of their actions.

We rated the practice as Requires Improvement for providing well-led services because:

• The practice showed leadership and appropriate governance in relation to succession planning and development. However, the practice was unable to demonstrate that governance systems and processes that were in place were always effective. Particularly in relation to recruitment and risk management.

We rated the practice as Good for providing effective and caring services because:

• Quality outlook framework (QoF) performance was in line with local and national averages in many areas, together with lower than average overall exception reporting.

• Cancer screening was in line with local and national averages for cervical, bowel and breast cancer.

• Patient feedback we received from patients relating to involvement in care and treatment was in line with local and national averages.

The areas where the provider must make improvements are:

• 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 areas where the provider should make improvements are:

• Continue to ensure that records relating to staff training are maintained in a comprehensive format.

• Review systems for identifying and supporting carers to ensure that proactive measures are taken.

• Continue to take action to improve childhood immunisation uptake.

• Continue to work to improve levels of patient satisfaction particularly in relation to access.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice