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Archived: Lozells Medical Practice

Overall: Requires improvement read more about inspection ratings

Finch Road Primary Care Centre, Lozells, Birmingham, West Midlands, B19 1HS (0121) 255 0250

Provided and run by:
Lozells Medical Practice

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

All Inspections

12 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We completed a comprehensive announced inspection at Lozells Medical Practice on 12 March 2015. Overall the practice is rated as requires improvement.

We found that the practice was good for providing an effective and caring service and required improvement for being safe and well-led. However, we found the practice to be inadequate for providing a responsive service. As a result, we found the practice required improvement in providing services for people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health.

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

  • Patients were at risk of harm because systems and processes in place to keep them safe were not effective. For example appropriate steps had not been taken to ensure sufficient numbers of staff were on duty on each occasion, systems in place regarding emergency equipment were not robust and the practice had not undertaken infection control audits.
  • Systems were in place to review the needs of those patients with complex health needs or those in vulnerable circumstances.
  • Patients said that the GPs listened to what they had to say and treated them with compassion, dignity and respect. However the results from the last national patient survey showed that the practice was below CCG and national averages regarding the percentage of patients who felt that they were involved in their care and decisions about their treatment.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments and that it was very difficult to get through the practice when phoning to make an appointment.
  • Staff felt supported by management and the practice proactively sought feedback from staff and patients, which it acted on.
  • There was an open culture within the practice and staff were actively encouraged to raise concerns and suggestions for improvement.
  • The practice had limited formal governance arrangements, not all staff had access to policies and procedures.

However, there were areas where the provider must make improvements

Importantly, the practice must:

  • Implement effective systems in the management of risks to patients and others against inappropriate or unsafe care. This must include robust management of recruitment of staff and environmental checks.
  • Ensure audit processes are in place to assess the risk, prevent, detect and control the spread of infection.
  • Implement systems to ensure that all complaints received are recorded and appropriate action is taken regarding investigation, corresponding with the complainant and review.

There were also areas where the practice should make improvements.

  • Implement Incident/significant event reporting, recording and monitoring processes to ensure trends and lessons learnt are captured and shared internally, and where appropriate externally.
  • Provide staff with information regarding the roles and responsibilities of a chaperone and ensure that the practice’s chaperone procedure is followed.
  • Ensure staff training records are well maintained so that the practice can be assured the training relevant to staff roles have been completed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 May and 27 June 2014

During an inspection in response to concerns

In order to target our inspections effectively we continually gather information about services. This may include information from health professionals and other staff; people who use services and family members. We had received information which led us to review circumcision procedures at a number of GP practices. CQC inspectors were accompanied by a specialist advisor in urology as part of these inspections.

We visited the practice twice. The first visit was unannounced; this meant that the provider and staff at the practice did not know we were coming. The second visit to the practice was announced. This was to ensure we had the opportunity to speak to the GP and staff working at the practice.

One of the GPs at Lozells Medical Centre was undertaking non 'therapeutic circumcisions, the term used for male circumcisions that are performed where there is no health need. They are generally completed for cultural reasons.

The process to gain consent from people with parental responsibility was inadequate and the consent was not appropriately recorded.

The planning and delivery of care and treatment did not ensure the welfare and safety of patients. The safeguard procedures were inadequate and did not protect the patient against the risk of harm or potential harm.

The systems in place for cleanliness and infection control were not robust. The lack of cleaning for some equipment generated the risk of healthcare acquired infection. The practice did not have systems in place to assess and monitor the quality of the service for patients who required a circumcision.

We were given assurance by the provider that circumcision procedures would no longer be undertaken at the practice. Should the provider wish to undertake the procedure in the future then they must satisfy CQC prior to commencing that the essential standards of quality and safety are being met.