The Care Quality Commission
  • Doctor
  • GP practice

Yardley Green Medical Centre Also known as Yardley Doctors

Overall: Requires improvement read more about inspection ratings

77 Yardley Green Road, Birmingham, West Midlands, B9 5PU (0121) 773 3737

Provided and run by:
Yardley Green Medical Centre

All Inspections

26 October 2023

During a routine inspection

We carried out an announced comprehensive inspection at Yardley Green Medical Centre on 26 October 2023. Overall, the practice is rated as requires improvement.

Safe - good

Effective – requires improvement

Caring – requires improvement

Responsive - requires improvement

Well-led - good

Following our previous inspection in July 2017, 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 Yardley Green Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The focus of inspection included a review of all key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A 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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. This included safeguarding systems, safe recruitment, infection prevention and control and the management of the premises and associated risks.
  • Our review of clinical records found safe management of medicines, in particular those that required ongoing monitoring due to adverse risks. However, processes for undertaking medicines reviews and alerts required improvement.
  • Systems were in place to support the practice to learn and make improvements when incidents and complaints occurred.
  • Patients received effective care and treatment that met their needs. Our review of clinical records found appropriate follow up of patients with or at risk of long-term conditions with the exception of asthma where improvements were needed to follow up patients requiring high doses of steroids.
  • Uptake of childhood immunisations and cancer screening programmes was below national targets and national averages.
  • Patient feedback from various sources was mixed about the way staff treated and involved them. Results from the GP national patient survey on questions relating to patient experience were lower than local and national averages.
  • The practice was taking significant action to try and improve access to services, which included a new telephone system, increased staffing and expansion of the premises. Early data available was showing signs of improvement, helping patients to 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. There was a strong emphasis of working with partners to tackle health inequalities.
  • The practice provided a supportive culture with clear direction for the future of the service.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

Whilst we found no breaches of regulations, the provider should:

  • Update policies accordingly, to ensure information contained within them is current and correct.
  • Take action to improve uptake of cervical screening and other other cancer screening programmes.
  • Take action to improve patient experience and patient involvement in the service to drive improvement.
  • Continue to monitor access to ensure improvements are being delivered and take further action as needed.
  • Improve systems and processes for the management of medicine and safety alerts.
  • Take action to improve the identification of carers so that they may receive appropriate support.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

23 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Waddell and partners practice also known as Yardley Green Medical Centre on 14 April 2016. The overall rating for the practice was good. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Dr Waddell and partners practice surgery on our website at www.cqc.org.uk.

This inspection was an announced desk based inspection carried out on 23 June 2017 to confirm that the practice had carried out their plan to meet the required improvements in relation to the breaches in regulations that we identified in our previous inspection on 14 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall, the practice continues to be rated as good.

Our key findings were as follows:

  • Documentation provided as part of our desktop review showed that all non-clinical staff had a Disclosure and Barring Service DBS check in place.

  • At our April 2016 inspection, health and safety risk assessment we viewed lacked sufficient details to enable effective management of risks. As part of our desktop review, the practice provided copies of their health and safety risk assessment, which showed clear procedures for monitoring and managing risks. The practice also provided copies of a detailed cleaning schedule policy which demonstrated measures to maintain standards of cleanliness.

  • Data from 2015/16 QOF year showed that overall clinical exception reporting rate remained above average. For example, 18%, compared to local and national average of 10%. The practice provided unverified data from 2016/17 QOF year which showed exception reporting for mental health, Asthma, Chronic Obstructive Pulmonary Disease (COPD) and cervical screening remained above local and national average. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects).

  • The practice was aware of their performance and continued to follow recognised processes to improve performance.

  • A nominated staff member was responsible for overseeing the patient recall system to ensure health review reminder letters were combined into one invite rather than patients receiving several different reminders letters. The practice also explained that they were planning to run several drop-in clinics for rheumatoid arthritis, dementia and other health related issues in order to offer more flexibility for patients to attend.

  • At our previous inspection, we found that the when responding to complaints the tone of the responses was not always sensitive to the concerns of the complainant.Documentation provided by the practice as part of this desktop review showed that the practice responded to complaints with openness and transparency.

  • Results from the January 2016 national GP patient survey showed that patients’ satisfaction with how they could access care and treatment was below local and national averages with the exception of patients who found it easy to make an appointment with a named GP.

  • Results from the July 2016 national GP patient survey showed that patient satisfaction had declined in some areas and improved in other areas. For example, satisfaction with the practice opening times and phone access had declined. However, access to a preferred GP had improved.

  • The practice carried out internal surveys to monitor patient satisfaction. Unverified data provided by the practice showed that within a three month period the practice answered between 94% and 98% of all calls.

  • The practice’s computer system alerted GPs if a patient was a carer. Staff we spoke with explained that since the previous inspection the practice updated their carers form and increased the amount of carers’ posters around the practice. We were also told that further improvements include updating carers’ information on the practice website and staff were developing a carer’s corner with the support of their patient participation group (PPG).

However, there were also areas of practice where the provider needs to continue to make improvements. For example, the provider should:

  • Continue to review national GP patient survey results and explore effective ways to improve patient satisfaction.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Waddell and Partners on 14 April 2016. Overall the practice is rated as good.

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

  • The practice was located in one of the most deprived areas in the country, it had a predominantly younger and cultural diverse population which created a challenge to the practice.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and were generally well managed but sometimes lacked the detail needed for staff to follow and did not include robust recruitment checks.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained and had the skills, knowledge and experience to deliver effective care and treatment. Data showed positive outcomes for patients.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they experienced difficulties accessing the service in particular getting through on the phone. The practice had recently installed a new telephone system which they hoped would improve the situation.
  • Patients were usually able to get an appointment with a named GP. 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 management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

The areas where the provider should make improvement are:

  • Review risk assessments in place to ensure they provide sufficient detail for staff to follow and effectively manage risks.
  • Review exception reporting where it is high to identify the reasons for this and implement any action as appropriate to improve patient uptake.
  • Review and monitor access to appointments to evaluate changes implemented and identify any further action required to improve patient satisfaction.
  • Review responses to complaints to ensure they are sensitive to the concerns of patients.
  • Review and implement ways in which the identification of carers might be improved so that they may receive support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice