We carried out an announced inspection at Hall Green Health on 14 December 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led -Outstanding
The practice has not been inspected under their current registration with CQC. However, the service was inspected under a previous registration on 16 December 2016. At the inspection in December 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 Hall Green Health on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection of Hall Green Health as a new registration.
How we carried out the inspection
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 shorter 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 Good overall and Outstanding in the well-led key question.
Our findings were as follows:
- We found Hall Green Health to be a high performing proactive service. We saw numerous examples of innovative working, the practice continually strived to improve services and was proactive in the use of information and learning from incidents and events occurring both internally and external to the practice. For example, a review of safeguarding arrangements and development of new comprehensive templates for recording information was undertaken in response to recent high-profile safeguarding incidents in the media.
- The practice had comprehensive management and governance structures in place to oversee and monitor services and identify where further improvements were needed. Teams worked together to help deliver improvements, in particular to improve the patient experience.
- Systems and processes implemented to drive improvement were regularly reviewed to identify progress and any adjustments needed. For example, the appointment system had been redesigned to improve patient access. Comprehensive real time information was made available to assess demand and capacity and ongoing daily monitoring had been implemented to identify adjustments needed. This had led to reviews of staffing requirements and individual roles. Proactive use of social media was used to help patients understand how to access the service.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. This included a comprehensive pandemic recovery plan to safely manage any backlogs caused by the pandemic. We identified some backlogs in the follow up of patients on high risk medicines as a result of the pandemic however, the practice had risk assessed their patients to ensure those most at risk were prioritised. The plan was supported by various Quality Assurance Monitoring processes as an additional safety net to reduce the risk of patients being missed from follow up during challenging times.
- The practice had put in place effective infection prevention and control (IPC) measures to protect patients and staff. This included videos on social media so patients knew what to expect when they attended the practice and complied with safe processes.
- Staff received appropriate training including refresher training. All doctors including partners underwent an in-depth inhouse appraisal which included consultation reviews and non-medical staff in advanced roles were allocated a clinical supervisor who they regularly liaised with.
- The provider was proactive in their use of social media to engage with their patients, this included videos recorded in local languages to promote cancer screening programmes and live question and answer events with clinicians online. The staff team employed a Communication Manager to help support ongoing engagement with patients.
- Patients received effective care and treatment that met their needs.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic, this was kept under regular review and was supported by their Pandemic recovery plan.
- The practice had historically struggled with patient satisfaction in relation to access and received low scores in the National GP Patient Survey, however, there had been significant commitment to addressing this and ensuring patients could access care and treatment in a timely way. Data from the practice showed how activity and appointments had increased during the pandemic and many online reviews were in contrast very positive about the service.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice demonstrated a commitment to addressing challenges and risk to patient services and used innovate approaches in order to ensure patients received safe and effective services. They worked with the local community in schemes to help improve the health and wellbeing of their population.
We saw the following outstanding practice:
- The practice had undertaken significant work to improve support to carers and in 2019 won a ‘Carer Friendly Business Award’ voted for by people for their work with carers. This had included the development of the carers champion who had worked to identify carers so that they could receive support. This had resulted in the carers register increasing from 2% to 5%. Carers events were introduced initially as monthly meetings prior to the pandemic and had been run virtually as personal conversations during the pandemic. Events were open to both carers registered at the practice and others. They provided opportunities for carers to receive health checks, third sector support, social prescribing and mental health and wellbeing support. The events were well attended and received positive feedback.
Whilst we found no breaches of regulations, the provider should:
- Continue to address backlogs in relation to high risk medicine reviews to ensure they are undertaken within approved intervals.
- Revisit coding for patients with diabetes / potential diabetes identified through blood tests to ensure they are receiving appropriate follow up.
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