The Care Quality Commission
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  • GP practice

Archived: The Acocks Green Medical Centre

Overall: Good read more about inspection ratings

999 Warwick Road, Acocks Green, Birmingham, West Midlands, B27 6QJ (0121) 706 0501

Provided and run by:
The Acocks Green Medical Centre

All Inspections

11 February 2020

During a routine inspection

We carried out an announced comprehensive inspection at Acocks Green Medical Centre on 11 February 2020 as part of our inspection programme.

The practice was rated as inadequate overall and for all key questions with the exception of caring and responsive and placed into special measures at our previous inspection in June 2019. You can read the report from our last comprehensive inspection on 26 June 2019; by selecting the ‘all reports’ link for Acocks Green Medical Centre on our website at www.cqc.org.uk.

This report covers our findings in relation to improvements made since our last inspection and any additional improvements we found at this inspection. The report covers our findings in relation to all five key questions and six population groups.

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.

At the time of the inspection the provider was absent from the practice. Alternative arrangements were in place for the management and leadership of the practice to support the implementation of the action plan in place to drive improvement and become compliant with Health and Social Act regulations.

We have rated this practice as good overall and good for all population groups, except children, families and young people and working age people (including those recently retired) which we rated as requires improvement in the Effective key question.

We rated the practice as requires improvement for children, families and young people and working age people (including those recently retired) in the effective key question because:

  • Childhood immunisation rates were lower than local and national averages.
  • Cervical cancer screening results were lower than national targets. The practice encouraged patients to attend their appointments and information was available at the practice on the importance of cancer screening.

We rated the practice good for providing safe, caring, responsive and well led services because:

  • The practice had implemented processes to ensure the safeguarding registers had been reviewed and updated to ensure they were appropriate. The local safeguarding lead had supported the practice to ensure the registers were accurate and up to date for vulnerable patients.
  • All patients on high risk medicines with outstanding reviews had been invited to attend the practice for follow up.
  • Systems and processes had been reviewed to ensure risk assessments were in place and monitored on a regular basis to mitigate risk.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. This included monitoring of safety alerts and ensuring all staff were aware of actions taken and learning was shared.
  • Patients received effective care and treatment that met their needs. Reviews of patients with complex needs had been completed. With the absence of the Principal GP, the clinical team had implemented a range of systems to monitor patients’ care through regular clinical audits and discussions at weekly clinical meetings.
  • The practice organised and delivered services to meet patients’ needs. The practice monitored telephone access to ensure peak times were being managed and had reviewed the roles of the clinical team to provide a co-ordinated care approach for patients.
  • The practice had positively embraced the concerns identified and had a risk stratification in place to ensure risks were prioritised and acted on. These included the prompt actioning of pathology results, reviewing safeguarding registers and the monitoring of patients on high risk medicines.
  • The leadership team had implemented regular meetings. These included clinical and practice meetings. Significant events, complaints and safety alerts were standing agenda items and evidence provided demonstrated that learning was shared across the team.

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

  • Continue to encourage patients to attend cervical screening appointments.
  • Continue with efforts to improve uptake of childhood immunisations and cancer screening overall.
  • Continue to monitor and improve telephone access.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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

26 June 2019

During a routine inspection

We carried out an announced comprehensive follow up inspection of The Acocks Green Medical Centre on 26 June.

The practice was initially inspected in May 2016 and received a rating of Requires Improvement overall. We noted improvement in our follow up inspection in January 2017 and therefore the practice was rated as Good overall. However, we found issues and gaps in evidence during a further inspection in August 2018, as a result the practices overall rating went back to Requires Improvement.

We carried out a further follow up inspection on 26 June 2019 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection on 1 August 2018.

The full comprehensive report and previous inspection reports can be found by selecting the ‘all reports’ link for The Acocks Green Medical Centre on our website at www.cqc.org.uk.

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.

Following this inspection we have rated this practice as Inadequate overall. Specifically, the practice was rated as Inadequate for providing safe, effective and well-led services. We rated the practice as Inadequate for proving effective care to families, children and young people, people with long term conditions, older people, people whose circumstances may make them vulnerable, people experiencing poor mental health (including people with dementia) and working age people.

On this inspection we found that:

  • Whilst staff we spoke with demonstrated good understanding of safeguarding principles, the practices systems and processes to keep people safe and safeguarded from abuse required strengthening in areas.
  • There were gaps in the practices systems for the appropriate and safe use of medicines and the practice had not always learned and made improvements when things went wrong.
  • Care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance.
  • The practice could not demonstrate how they assured the competence of staff employed in advanced clinical practice. Specifically, there was no formal evidence provided by the practice to demonstrate a regular review of their nurses prescribing practice supported by clinical supervision or peer review.
  • Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets in certain areas. Cervical and breast screening uptake was consistently below local and national averages.
  • The practice did not always operate effective processes for managing risks, issues and performance.
  • Leaders could not fully demonstrate that they had the capacity and skills to deliver high quality sustainable care and during our inspection we received conflicting information with regards to the scope of a role within the nursing team; specifically the evidence found thereafter did not promote a culture of candour, openness and honesty at all levels.
  • Feedback from patients was mostly positive about the way staff treated people. Staff described the practice as a positive environment in which to work.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Strengthen systems to support timelier reviews of urgent pathology results.
  • Continue with efforts to improve uptake of childhood immunisations and cancer screening overall.
  • Explore further ways to identify and capture carers to ensure their care and support needs are met.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, we place it into special measures. Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the service the reassurance that the care they get should improve. We are currently carrying out enforcement actions against the provider and will report on the outcomes at a later date.

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

1 August 2018

During a routine inspection

This practice is rated as Requires improvement overall. (Previous rating 11 January 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

We previously carried out an announced comprehensive inspection at The Acocks Green Medical Centre on 11 January 2017 as part of our inspection programme. We carried out an unannounced focused inspection on 31 May 2018 in response to concerns received. The full comprehensive report on the 11 January 2017 inspection and the unannounced focused report on the 31 May 2018 inspection can be found by selecting the ‘all reports’ link for The Acocks Green Medical Centre on our website at .

At this inspection we found:

  • There were areas where risk was not being assessed or managed effectively. For example, health and safety risk assessment did not identify all risks, the fire risk assessment had not been reviewed since June 2016 and risk assessments to cover the full range of substance hazardous to health had not been carried out.
  • Clinical waste was not appropriately labelled in a way which enabled the waste to be classified correctly so that it was managed appropriately upon collection.
  • In the absence of some suggested emergency medicines the practice did not carry out a risk assessment to mitigate risks.
  • The practice did not operate an effective staff immunisation programme and were unable to demonstrate how they mitigated risks to staff who had direct contact with clinical specimens’.
  • The practice had clear systems to manage safety incidents so that they were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines. Staff were aware of the practice Quality Outcome Framework results and were taking action to improve areas where performance was below local and national averages.
  • National GP patient survey results showed that patients felt involved in their care and treatment, staff were caring and patients felt listened to. Survey results showed that patients were treated with compassion, kindness, dignity and respect.
  • Completed Care Quality Commission comment cards showed that patients did not always find the appointment system easy to use and reported that they were not always able to access care when they needed it. National survey results were below local and national average regarding access. Staff were aware of this and took action to improve patient access.
  • There was a focus on continuous learning and improvement.
  • The practice demonstrated a clear understanding of the practice population group and created referral pathways to community support groups. For example, the practice was a Armed Forces Veteran friendly accredited practice. Veterans were identified and signposted to services which offered them as well as their families support.
  • The leadership, governance and culture were used to drive and improve the delivery of its service. All staff were involved in the development of the practice. However, we found some gaps in the practice governance arrangements. For example, there was no written protocol for Patient Specific Directives, there was a lack of effective monitoring systems in place for the safety of the service, some risks had not been mitigated and some protocols had not been reviewed.

The areas where the provider must make improvements are:

  • 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.

The areas where the provider should make improvements are:

  • Take action to increase the number of health checks carried out for patients on the practice learning disability register.
  • Continue taking action to improve the uptake of national screening programmes.
  • Take action to ensure privacy and dignity is maintained at all times.
  • Continue taking action to improve patient satisfaction.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

31 May 2018

During an inspection looking at part of the service

We carried out an unannounced focused inspection on 31 May 2018 in response to information regarding the lack of GP appointments and clinical cover. On the day of our inspection, the principal GP was on leave; a locum GP was covering the morning clinic and the practice closed during the afternoon for staff training. The practice is a three GP partnership, at the time of our inspection, staff explained one partner had physical day to day presence at the practice. During this inspection, CQC only reviewed areas where concerns had been reported.

A full comprehensive inspection of The Acocks Green Medical Centre was undertaken on 11 January 2017. The full report is available on CQC website.

At this inspection we found:

  • National GP survey results published July 2017 showed that patients found the appointment system easy to use; however, satisfaction regarding timely access to care were below local and national averages.
  • Staff were aware of low patient satisfaction in areas such as appointment access and were taking action to improve patient satisfaction.
  • Although, the practice had arrangements with Birmingham and District General Practitioner Emergency Rooms (BADGER) medical services to enable access to medical care during Wednesdays and Thursday afternoons; the practice website and leaflet did not provide clarity regarding the availability of GP appointments at the practice during Thursday afternoon.
  • Staff we spoke with were clear regarding their responsibilities, roles and systems of accountability to support governance and management within the practice. For example, complaints and concerns were managed and responded too in a timely manner.

The areas where the provider should make improvements are:

  • Continue to carry out actions to improve patient satisfaction in areas where survey results were below local and national areas.
  • Continue exploring ways to increase clinical capacity through appropriate recruitment and monitoring of staffing levels.
  • During the implementation of the new file sharing platform, ensure staff have access to practice documents such as records of complaints and minutes from practice meetings.
  • Ensure practice leaflets and details on the practice website provide clarity on GP appointment times.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

11 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Acocks Green Medical Centre on 4 May 2016. Following that inspection the overall rating for the practice was requires improvement. The full comprehensive report for the May 2016 inspection can be found by selecting the ‘all reports’ link for The Acocks Green Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken to follow up progress made by the practice since the inspection on 4 May 2016. It was an announced comprehensive inspection on 11 January 2017. Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice had been proactive in responding to the findings of the previous CQC inspection to improve the service delivered. We found significant improvements had been made since the inspection in May 2016.
  • 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 well managed.
  • 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.
  • Patient outcomes were mostly in line with CCG and national averages with the exception of diabetes and cervical screening.
  • 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 were able to obtain appointments when needed with urgent appointments available the same day. The appointment system had been reviewed leading to an increase in available appointments.
  • 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.

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

The provider should:

  • Continue to improve the uptake of cervical screening and identify how uptake of national screening programmes for breast and bowel cancer may be improved.
  • Review systems to improve outcomes for patients with diabetes.
  • Review registration with CQC to ensure it is current and correct.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Acocks Green Medical Practice on 4 May 2016. Overall the practice is rated requires improvement.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. There was an effective system in place for reporting and recording significant events.
  • Some risks to patients had been assessed and were well managed however, this did not include those relating to staffing, recruitment checks and prescription safety.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Systems to ensure staff had the skills, knowledge and experience to deliver effective care and treatment were not sufficiently robust.
  • 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.
  • Most patients said they were able to make an appointment with urgent appointments available the same day. However, some patients told us they found it difficult to make appointments by telephone and there was a long wait for the next available routine appointment with a GP.
  • The practice was accessible and well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from patients and had acted on this but meetings were infrequent.
  • 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 that the recruitment process includes all necessary pre-employment checks for staff.
  • Establish systems to ensure staff receive appropriate support, supervision and training relevant to their roles and responsibilities.
  • Ensure robust management of risks in relation to staffing, prescription handling and business continuity in the event of disruption to the service.

The areas where the provider should make improvement are:

  • Review processes to try and encourage greater uptake of cervical screening for relevant patients.
  • Ensure patients are aware that there is an alternative entrance for patients who use a wheelchair.
  • Develop systems for recording verbal and informal complaints in order to identify themes and trends and to support learning.
  • Ensure carers at the practice can be easily identified so that they can be appropriately supported and their needs accommodated and identify processes to support those who are recently bereaved.
  • The practice should review access to appointments and identify how this may be improved.
  • Review processes for scanning patient information so that it is available on the patient record in a timely manner.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice