The Care Quality Commission
  • Doctor
  • GP practice

Meadowbrook Surgery

Overall: Requires improvement read more about inspection ratings

4, Meadowbrook Road, Halesowen, West Midlands, B63 1AB (0121) 550 1034

Provided and run by:
Meadowbrook Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Meadowbrook Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Meadowbrook Surgery, you can give feedback on this service.

14 September 2023

During a routine inspection

We carried out an announced comprehensive inspection at Meadowbrook Surgery on 14 September 2023. Overall, the practice is rated as requires improvement.

Safe – requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

Following our previous inspection on 17 August 2015, 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 Meadowbrook Surgery 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.

This was a comprehensive inspection to review the following domains:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led

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 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 found that:

  • Patients’ needs were assessed; however, care and treatment was not always delivered in line with current standards and evidence-based guidance. For example, we identified concerns in relation to medicines management, the diagnosis of conditions, and monitoring and follow-up of patients with long-term conditions.
  • Medicines and Healthcare products Regulatory Agency alerts were not always promptly actioned.
  • The practice learned from incidents, events and complaints and ensured learning was shared amongst the staff team.
  • We found the premises were well maintained, appeared clean and tidy and had appropriate infection prevention and control arrangements in place.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • There were governance systems in place, however they did not always work effectively, in particular the oversight of medicines management and the coding of patients with diagnosis or long term conditions.

We found a breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found a breach of regulation, the provider should:

  • Take steps to ensure all risk assessments are carried out for all staff where a disclosure and barring check has not been required.
  • Take action to complete mandatory training for staff employed at the practice.
  • Take action to ensure safeguarding registers are reviewed and accurate.
  • Take action to complete sepsis training.
  • Take action to record the day of the week for patients prescribed Methotrexate in line with best practice.
  • Take action to review patients in a timely way where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is in place.

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

28 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Meadowbrook Surgery on 28 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. We also inspected the quality of care for six population groups which were, 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. We rated the care provided to these population groups as good.

Our key findings were as follows:

  • There were systems in place to ensure patients received a safe service. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, reviewed and addressed.
  • There were effective arrangements in place to identify, review and monitor patients with long term conditions. Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice was responsive to the needs of the practice population. There were services aimed at specific patient groups. The complaints procedure was accessible to patients.
  • There was visible leadership with defined roles and responsibilities and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw areas of outstanding practice including:

  • The practice had taken action to improve the management and treatment of diabetic patients. The practice had employed a diabetic nurse specialist who worked in conjunction with one of the GPs and established a dedicated diabetic clinic two days a week. To date, 130 patients had been discharged from the hospital diabetic clinic and 280 patients were under the sole care of the practice.
  • The practice had taken action to improve the number of patients aged between 40 years and 74 years who received the NHS health check. An audit had been undertaken and a protocol developed. The practice undertook a targeted approach which included the appointment of a Health Care Assistant to undertake the check. This significantly increased the number of NHS health checks offered and the practice went from a completion rate of 8% to 80% within a 10 month period. This resulted in the practice being rate within the top 5% of practices for completion of the check within the Clinical Commissioning Group (CCG).
  • The practice used the Choose and Book system for making the majority of patient referrals. The Choose and Book system enables patients to choose at which hospital they would prefer to be seen. The practice had a system in place for offering choose and book which enabled 95% of patients to walk away with an appointment for their chosen hospital on the same day they were seen by the GP.

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

The provider should:

  • Develop a policy for significant events for staff to follow to ensure a consistent approach.
  • Ensure appropriate signage is in place to alert people of the risks associated with flammable liquids and oxygen.
  • Ensure reasonable adjustments are made to enable people who require the use of a wheelchair are able to access the service.
  • Proactively undertake dementia screening for patients to ensure early identification and intervention.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 January 2014

During a routine inspection

On the day of our inspection we spoke with eight patients and seven members of staff. One patient said, 'Very courteous and helpful, it is excellent really." All of the patients we spoke with said they were able to obtain appointments at a time to suit their needs. All the patients we spoke with said they felt the quality of care they received was good.

We saw that patient's views and experiences were taken into account in the way the service was provided and that they were treated with dignity and respect. One patient told us, 'You feel as if you are the only one." We saw that patients experienced care and treatment that met their needs.

Patients told us and we saw that care was delivered in a clean environment. However, some improvements were required in staff training on current infection control practice.

Staff required training in safeguarding (protecting vulnerable adults and children) but were aware of whom to report concerns to.

Improvements were required to the quality monitoring systems to assess and monitor the quality of service that patients received. The quality monitoring of chronic disease management required improvement. The systems of incident and accident reporting required improvement.