24 November 2023
Bucklands End Lane Surgery is located in the Castle Bromwich area of Birmimgham at:
36 Bucklands End Lane
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 Birmingham and Solihull (BSOL) Integrated Care Board (ICB) and provides General Medical Services (GMS) to a patient population of about 6,200. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices Birmingham East Central Primary Care Network (PCN).
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the second lowest decile (two 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 29% Asian, 59% White, 7% Black, 4% Mixed, and 1% Other.
The age distribution of the practice population mirrored the local and national averages. There are equal numbers of male patients registered at the practice compared to females.
The practice has 3 GP partners (2 male and 1 female). The practice team includes a practice nurse who provides nurse led clinics for long-term condition, a clinical pharmacist, an advanced nurse practitioner, 2 health care assistants and a physicians associate. The clinical staff are supported at the practice by a practice manager and a team of reception and administration staff.
The practice is a training practice for fifth year medical students and GP trainees.
The practice is open between 8.30 am to 6.30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
Extended access is provided at the practice on a Tuesday evening 6.30 pm - 8 pm.
Appointments on Saturday are available 9 am to 5 pm through PCN arrangements.
When the practice is closed and on Wednesday and Thursday afternoons after 1pm and all day Saturday the phone lines are transferred to the out of hours provider BADGER.
24 November 2023
We carried out an announced comprehensive at Bucklands End Lane Surgery on 19 September 2023. Overall, the practice is rated as requires improvement.
Safe - requires improvement,
Effective - good,
Caring – requires improvement,
Responsive - requires improvement,
Well-led – good.
During the inspection process, the practice highlighted efforts they were making to improve telephone and appointment access for their patient population. These had only recently been implemented so there was not yet verified evidence to show they were working and had improved patient satisfaction.
The provider also told us of their plans to expand the premises, however these plans were awaiting planning permission and had not been confirmed.
As such, the ratings for this inspection have not been impacted by these improvement initiatives. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.
Following our previous inspections, the practice was rated good overall and for all key questions.
At this inspection, we found some areas that required improvement in the safe, caring and responsive key questions. The practice is therefore now rated requires improvement overall.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bucklands End Lane 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.
We inspected the following 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.
- 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 shorter site visit.
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:
- Most safety and governance systems the provider had implemented, kept patients safe and protected them from avoidable harm.
- Some systems such as the management of infection prevention and control, security of blank prescriptions and calibration of medical equipment required improvement.
- Patients received effective care and treatment that met their needs.
- Patients on high risk medicines or those patients with long term conditions were monitored and followed up in line with guidelines.
- The provider was aware that uptake with children’s immunisations was below target and they were taking appropriate action to improve this.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patient feedback indicated that patients could not always access care and treatment in a timely way. However, the provider was taking appropriate action to improve access.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The provider was aware of the challenges it faced and told us of the action they had taken to improve. The provider responded to any concerns that were raised during the inspection and took immediate action to improve the safety of services.
We found breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
The provider should:
- Continue to take action to improve telephone and appointment access.
- Improve processes to be able to demonstrate that the impact of actions taken to improve patient satisfaction are being monitored and further action is taken when actions have not had the desired outcome.
- Improve governance of health and safety processes to include monitoring and mitigation for all possible risks and hazards relating to staff and premises.
- Take action to improve uptake of cervical cancer screening.
- Take action to improve processes to ensure all carers including young carers are identified.
- Continue to take action to improve uptake with childrens’ immunisations.
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