The Care Quality Commission
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  • GP practice

Archived: Church Road Surgery

Overall: Requires improvement read more about inspection ratings

90 Church Road, Sheldon, Birmingham, West Midlands, B26 3TP 0844 375 6565

Provided and run by:
Church Road Surgery

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

All Inspections

30 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We first inspected Church Road surgery on 6 May 2016 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement, with well led rated as inadequate. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Church Road surgery on our website at www.cqc.org.uk. During the inspection in May 2016 we found the practice required improvements in a number of areas. The areas which required improvement related to appropriate processes which were not in place to mitigate risks in relation to the safety and quality of the services. Feedback had not been sought from service users to demonstrate improvement to services. Following the inspection the practice wrote to us to say what they would do to meet the regulations.

We undertook this planned comprehensive inspection on 30 March 2017 to check that the practice had followed their action plan and to confirm that they had made the required improvements. Overall we found some improvements had been made to the concerns raised at the previous inspection. However, concerns relating to effective processes to manage risk and monitor patient outcomes had not been established. As a result of the inspection findings the practice is rated as requires improvement.

Our key findings were as follows:

  • The practice had no system in place to receive alerts from the Medical and Healthcare products Regulatory Agency (MHRA) alerts.
  • On the day of inspection, the practice did not have an effective system in place for the recall of patients on high risk medicines.
  • There was no system in place to ensure clinical staff were up to date with NICE guidelines.
  • The practice did not have an effective system in place to monitor expiry dates of medicines carried by GPs.

  • Emergency medicines were easily accessible to staff in a secure area of the practice, but we found that some staff were not aware of their location.

  • Staff we spoke with did not know the process for reporting significant events. We found that no events had been recorded in the significant events log since May 2016.
  • Quality performance data showed patient outcomes was lower than local and national averages in 2015/16. Unverified data provided by the practice for 2016/17 showed some improvement, but the recall system to review patients with long term conditions was not effective in monitoring patients.
  • At the previous inspection in May 2016, 1% of the practice list were registered as carers. The practice attributed the low numbers to coding errors.
  • Complaints were actioned by the practice; however we were unable to evidence any learning or improvements made following patient feedback.
  • At the previous inspection the provider did not have risk assessments or disclosure and barring checks (DBS) for reception staff who acted as chaperones. We found this had been acted on and the appropriate DBS checks were now in place.
  • Staff immunisation status identified as not being in place at the inspection in May 2016 had been recorded and we saw evidence to confirm that the practice had ensured all staff were up to date with the recommended immunisations for working in general practice.
  • At the inspection in May 2016 we found staff had not had appraisals and communication with all staff was identified as an area for improvement. At this inspection we found staff had received appraisals and departmental meetings were now taking place on a regular basis.
  • Patient Specific Directions (PSD) were found not to be in place at the inspection in May 2016. These had been implemented for the administration of vaccines by the health care assistant.

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

Importantly, the provider must:

  • Have an embedded system in place to act on safety alerts and national guidance.
  • Monitor quality and outcome framework (QOF) indicators and national targets to ensure patient reviews are up to date and completed.
  • Ensure processes are in place for handling complaints and patient feedback is acted on. Implement a system to share learning of actions taken and lessons learnt with the staff.

In addition the provider should:

  • Continue to review appointment access to increase availability of appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Road Surgery on 5 May 2016. Overall the practice is rated as requires improvement. There are two surgery locations that form the practice; these consist of the main practice at Church Road and the branch practice at Tile Cross Surgery. Systems and processes are shared across both sites. During the inspection we visited both locations. As the locations have separate CQC registrations we have produced two reports. However where systems and data reflect both practices the reports will contain the same information.

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

  • The practice had defined and embedded systems in place to keep people safeguarded from abuse. There was a system in place for reporting and recording significant events and staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses.
  • Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment and results were circulated and discussed in the practice.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Some staff had not received regular appraisals.
  • We observed the premises to be clean and tidy.
  • 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.
  • Due to resignation of four GP Partners, the practice had employed locums to ensure that appointments were available daily.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Governance and risk management arrangements were in place, but were not operating effectively and therefore the provider did not have appropriate oversight of risk. For example no risk assessments had been completed in the absence of disclosure and barring checks (DBS) for members of the reception team who occasionally chaperoned.
  • Poor performance in relation to QOF and screening had been considered with action plans in place to mitigate this.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. We saw evidence that quarterly multidisciplinary team meetings took place.

The areas where the provider must make improvements are:

The provider did not have effective systems to enable them to identify, assess and mitigate risks by;

  • Seeking and acting on feedback received to demonstrate improvements to services.
  • Keeping records to demonstrate that staff were up to date with the immunisations recommended for staff who are working in general practice, such as Hepatitis B, mumps and rubella (MMR) vaccines.
  • Ensuring all staff are risk assessed in the absence of a Disclosure and Barring Service (DBS) check when carrying out chaperoning duties.

Patients were not protected against the risks associated with receiving unsafe care or treatment in that;

  • Patient Specific Directions were not in place for patients who received vaccinations by the Health Care Assistant.

The areas where the provider should make improvement are:

  • Ensure staff who chaperone are aware of and comply with recommended chaperoning guidelines when observing treatments and examinations.
  • Review current processes for ensuring patients with a learning disability receive annual health checks.
  • Ensure that staff are informed and involved in the overall vision of the practice.
  • Complete appraisals for all staff including development plans.
  • Monitor quality and outcome framework (QOF) indicators to ensure patient reviews are up to date and completed.
  • Continue to review the registers for patients with long term conditions and mental health needs to ensure appropriate reviews are in place.
  • Consider how to proactively identify and support carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice