The Limes Medical Centre

Updated 28 April 2022

The Limes Medical Centre is located at:

172 High Street

Lye

Stourbridge

West Midlands

DY9 8LL

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury, family planning and surgical procedures.

The practice is situated within the Black Country and West Birmingham Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 6,514. This is part of a contract held with NHS England.

Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three out of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 82% White with a further 18% from Black, Asian, mixed or other non-white ethnic groups.

The practice team includes three GP partners (one partner had resigned at the time of our inspection), a salaried GP, an advanced nurse practitioner (ANP), a nurse practitioner, a practice nurse and a healthcare assistant. The practice is supported by a practice manager and a team of administrative and reception staff.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, GP appointments were both telephone consultations and face to face.

Out of hours services are provided by West Midlands Ambulance Service. These are available by contacting NHS 111.

Updated 28 April 2022

We carried out an announced inspection at The Limes Medical Centre on 17 March 2022. Overall, the practice is rated as Requires Improvement.

The ratings for each key question are as follows:

Safe - Requires Improvement

Effective - Good

Well-led – Requires Improvement

Following our previous inspection on 15 November 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 The Limes Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection for Safe, Effective and Well-led due to concerns around the safety, governance and management of the practice.

How we carried out the inspection/review

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 Requires Improvement overall

We found that:

• There was a lack of oversight of safeguarding processes to keep people safe and safeguarded from abuse.
• There were gaps in safeguarding training and not all staff were trained to the appropriate levels for their role.
• There was an absence of appropriate staff recruitment checks to ensure safety.
• Checks of staff immunisation status or appropriate risk assessments had not been completed for all staff.
• The process for reporting and learning from significant events needed strengthening with all staff as the practice did not always share learning and improvements.
• Patients received effective care and treatment that met their needs.
• 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.
• There was a lack of good governance in some areas and monitoring procedures were not always carried out consistently and effectively.
• There were systems for managing risks, issues and performance, however this needed strengthening to ensure that the services were safe or that the quality was effectively managed.
• There was limited evidence to demonstrate that the practice involved patients, staff or stakeholders in shaping the service.
• The practice culture did not effectively support high quality sustainable care.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found breaches of regulations, the provider should:

• Continue to embed processes for infection prevention and control.
• Continue to strengthen processes for the recall and reviewing of patients with long term conditions.
• Continue to increase the uptake for cervical screening.
• Implement processes to engage with staff and patients so that learning can be shared, and quality of services provided can be improved further.
• Continue with steps to engage with a patient participation group.

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