Background to this inspection
Updated
24 December 2021
OHP-Poolway Medical Centre is located in purpose-built health centre which they share with a community health team in the Kitts Green area of Birmingham at:
80 Church Lane
Kitts Green
Birmingham
West Midlands
B33 9EN
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.
The practice is situated within the Birmingham and Solihull Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 2,075. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices called the Bordesley Green Primary Care Network (PCN). PCNs are groups of practices working together to improve and develop services locally.
The practice is also part of Our Health Partnership (OHP) who bringing together 43 surgeries in the Midlands and Shropshire. OHP has a centralised team to provide support to member practices in terms of quality, finance, workforce, business planning, contracts and general management, whilst retaining autonomy for service delivery at individual practice level.
Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one of 10). The lower the decile, the more deprived the practice population is relative to others.
The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.
The practice is a partnership of two GP partners (both female). The partners are supported by locum GPs. The practice has a practice nurse who works one day a week. The practice manager provide managerial oversight and is supported by reception/administration staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Extended access is provided locally at another local practice through the extended access hub arrangements, where late evening and weekend appointments are available. Out of hours services are provided by BADGER.
Updated
24 December 2021
We carried out an announced inspection at OHP-Poolway Medical Centre on 09 August 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question:
Safe – Requires Improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led – Good
Following our previous inspection on 5 February 2020, the practice was rated Requires Improvement overall and Good for three key questions but requires improvement for providing responsive and well-led services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for OHP-Poolway Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to follow up on:
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Key questions inspected
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Breaches of regulations and ‘shoulds’ identified in previous inspection
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Information received from stakeholders as well as feedback relating to patients’ experience
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Ratings carried forward from previous inspection
How we carried out the inspection/review
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 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
- A short 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 have rated this practice as Good overall and good for all population groups; except, families, children, and young people population group which we rated requires improvement.
We found that:
- Prescribing data showed significant improvements in relation to antibiotic prescribing over the previous 12 months. Patients treatment plans were adjusted as well as referrals to services to support patients with non-clinical interventions to manage pain.
- Data showed that the practice uptake of childhood immunisation continued to remain below national targets.
- The practice was not meeting national targets for cervical cancer screening uptake.
- Data from the March 2020 national GP survey indicated that patient satisfaction was comparable to local services. However, feedback and comments placed on various platforms showed that patients were less positive about staff attitudes and getting through to the practice by phone.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a range of ways such as video consultations.
- The practice did not have an effective system for the oversight and monitoring of quality assurance, including clinical audit.
We rated the practice as requires improvement for providing safe services because:
- The practice did not have an effective system for monitoring the recruitment process; in particular gaining assurance that clinical staff who were employed through a recruitment agency had completed training and demonstrated they were skilled and competent to carry out their role.
- There was a lack of an effective system to manage patient safety alerts as well as ensuring routine application of national guidelines.
- The monitoring of significant events did not routinely demonstrate that actions identified by the provider to remedy the situation had been completed in their entirety.
We found a breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
We also found areas where the provider should improve:
- Continue taking action to improve the uptake of childhood immunisation and accuracy of data; as well as improving the uptake of cervical screening.
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