Glebefields Surgery

Background to this inspection

Updated 21 November 2017

Dr Raymond Sullivan (also known as Glebefields Surgery) is located at Glebefields Health Centre, Tipton an area of the West Midlands. The health centre is owned by NHS Property Services with consulting rooms on two floors. The surgery is located on the upper floor with access to lifts. There is easy access to the building and disabled facilities are provided.

The practice has a General Medical Services contract (GMS). A GMS contract is a nationally agreed contract to provide essential services for people who are sick as well as, for example, chronic disease management and end of life care. The practice also provides some enhanced services such as childhood vaccination and immunisation schemes.

The practice provides primary medical services to approximately 4,300 patients in the local community. The practice is run by a lead male GP (provider) and one long term locum (female). There are two female nurses and one female health care assistant. (HCA). The non-clinical team consists of administrative and reception staff, a practice manager and a personal assistant.

Based on data available from Public Health England, the levels of deprivation in the area served by Dr Raymond Sullivan are below the national average ranked at one out of ten, with ten being the least deprived.

The practice opening times are 8am until 6.30pm Mondays to Fridays. The practice did not offer extended hours appointments, but had joined the Black Country extended hours hub where patients were able to access appointments from 6.30pm to 8pm Monday to Friday and 9am to 12pm on Saturdays and 9am to 11am on Sundays. The practice also offered an express clinic after each morning surgery for patients who needed to see the GP urgently. When the practice is closed, primary medical services are provided by Primecare, an out of hours service provider and NHS 111 service.

The practice is part of NHS Sandwell & West Birmingham CCG which has 91 member practices. The CCG serve communities across the borough, covering a population of approximately 559,400 people. (A CCG is an NHS Organisation that brings together local GPs and experienced health care professionals to take on commissioning responsibilities for local health services).

Overall inspection

Good

Updated 21 November 2017

Letter from the Chief Inspector of General Practice

We first inspected Dr Raymond Sullivan’s surgery on 16 November 2016 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Ray Sullivan’s surgery on our website at www.cqc.org.uk. During the inspection, we found the practice was in breach of legal requirements this was because appropriate processes were not in place to mitigate risks in relation to the safety and quality of the services offered. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.

This inspection was an announced focussed inspection, carried out on 13 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall we found improvements had been made to the concerns raised at the previous inspection and as a result of our inspection findings the practice is now rated as Good.

Our key findings across all the areas we inspected were as follows:

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Since the previous inspection, an effective system had been implemented to ensure all incidents were acted on and learning was shared with all staff members. The practice carried out an analysis of each event with a documented action plan.
We found that the practice had reviewed their processes for receiving safety alerts and all alerts were actioned upon receipt and actions taken were recorded and discussed as part of the clinical team meetings, which were held every week.
At this inspection, we saw a programme of clinical audits had been implemented to monitor patients’ outcomes and improve the quality of care provided.
We saw evidence to confirm that staff had received the appropriate checks with the disclosure and barring service (DBS).
At our previous inspection we found the practice did not have effective systems and processes to monitor patients on high risk medicines. This risk had been mitigated with the implementation of guidelines to monitor patients on high risk medicines, the support of a clinical pharmacist and a review of all patients to ensure they were receiving the appropriate care.
The practice had a number of governance policies and procedures in place, which had been reviewed and updated. The governance arrangements to assess and monitor the

quality of services showed improved outcome with a schedule of regular governance meetings in place since the last inspection in November 2016. This included monthly team meetings and weekly clinical meetings.

At this inspection we saw evidence that an IT training needs analysis had been completed and identified gaps in staff’s IT knowledge had been actioned.
The practice proactively sought feedback from staff and patients, however at our previous inspection, we were told there was a patient participation group (PPG) but they did not meet regularly and were not actively involved in practice developments. At this inspection, the practice told us they had tried to encourage patients to join the group and had sought support from the clinical commissioning group (CCG). A virtual group had been planned and the practice were still looking at this possibility. A PPG meeting had been arranged for the end of October 2017 which was on display in the waiting room to advise patients.
The practice had achieved in cervical screening with 91% of patients having had a cervical screening test in the past five years, the practice had been asked to participate in a cervical screening workshop for primary care providers by Public Health England to share good practice and educate primary care about strategies to increase cervical screening coverage.
Following our previous inspection, the practice had recruited a clinical pharmacist to support the GPs in monitoring prescribing and effective auditing of medicines.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice