We carried out an announced inspection at Weoley Park Surgery between the 20 July 2022 and 25 July 2022. Overall, the practice is rated as Good.
The ratings for each key question are as follows:
Safe - Good
Effective – Good
Caring – Good
Responsive – Good
Well-led - Good
Following our previous inspection on 6 September 2016, the practice was rated Good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Weoley Park Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection as part of our band one pilot inspections of practices previously rated good or outstanding. This was to pilot the changes to how CQC are monitoring services in response to the pandemic.
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 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
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Safeguarding arrangements had been developed to help support and protect the practice’s most vulnerable patients.
- We found the premises was well maintained and both the main and branch surgery had undergone recent refurbishment.
- Infection prevention and control measures were in place to minimise the risks to patients.
- Our clinical searches found medicines were well managed.
- The practice learned from incidents and complaints and had implemented systems for minimising the risk of reoccurrence.
- Patients received effective care and treatment that met their needs.
- Our review of clinical records found patients with long-term conditions received appropriate management and follow-up.
- However, there was low uptake of some child immunisations and cervical screening.
- The practice had a strong culture of learning and development of staff to meet the needs of their patient population.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- 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 timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Implement systems for recording ongoing checks of clinical staff registration with their professional bodies to ensure they are kept up to date.
- Implement systems for recording weekly fire alarm testing to confirm it has been done.
- Record the issuing of steroid cards, where appropriate.
- Risk assess the non-wipeable chair in the isolation room, and take action as appropriate.
- Strengthen systems to encourage attendance from patients who regularly do not attend for their long term condition or medicine reviews, in particular those with more complex care needs.
- Improve childhood immunisation and cervical screening uptake.
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