• Doctor
  • GP practice

Archived: Drs Yap and Michael

Overall: Requires improvement read more about inspection ratings

Maypole Health Centre, 10 Sladepool Farm Road, Kings Heath, Birmingham, West Midlands, B14 5DJ

Provided and run by:
Drs Yap and Michael

Important: The provider of this service changed. See new profile

All Inspections

11 September 2019

During a routine inspection

We carried out an announced focused inspection at Drs Yap, Hughes and Michael on 11 September 2019, following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Safe
  • Effective
  • Responsive
  • Well-led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Caring

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 and well led services because:

  • There were some systems and processes in place to keep people safe. However, these were not always identified, sufficiently well managed or embedded to ensure their effectiveness.
  • There was a lack of effective leadership oversight to ensure good governance. The practice did not always have clear and effective processes for managing risks, issues and performance.

We rated the practice as good for providing effective and responsive services because:

  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was consistently positive. This included the results of the national GP survey, CQC comment cards and patient interviews.
  • Overall, patients could access care and treatment in a timely way. Some patients reported that access to appointments was difficult, the practice was taking action to address this.

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 promote and explore ways to improve the uptake of cancer screening.
  • Continue to explore ways to improve access for patients.

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

6 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Yap, Hughes and Michael’s practice on 6 May 2015. Overall the practice is 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 to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and managed, although actions taken in relation to risks were not always well documented.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients were able to make an appointment with a named GP and urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by the senior partners. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Ensure robust records are maintained in relation to the governance of the practice including risks, audit actions and staff meetings to ensure actions required are not missed.
  • Ensure legionella risk assessments have been completed for the premises and actions identified implemented.
  • Ensure doctor’s bags are routinely checked to ensure items contained within them are within their expiry date and fit for use.
  • Ensure systems are in place for ensuring findings from audits are discussed and where appropriate implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice