The Acocks Green Medical Centre

We carried out an announced comprehensive inspection at The Acocks Green Medical Centre on 5 July 2022. The practice is rated as requires improvement overall.

Safe – Good

Effective – Requires Improvement

Caring – Good

Responsive – Requires Improvement

Well-led – Good

This was the first inspection since the practice re-registered under a new provider in July 2020.

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This inspection was also planned to follow up concerns raised by patients relating to access.

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 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.
• The practice had taken appropriate action to support and protect patients identified as at risk from harm. Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
• The practice had a system for recording and disseminating actions carried out as a result of significant events.

We found that:

• There continued to be a poor uptake by patients of preventative treatments and screening procedures. In particular, childhood immunisations and cervical screening.
• The cervical screening rates for the practice were significantly below the national target.
• The practice uptake for childhood immunisations were below the WHO minimum uptake for all five immunisation indicators.
• There were gaps in staff records, the practice management team was taking action to ensure clear, accurate and up to date staff information was available for all staff.
• 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 had management oversight of staff qualifications and training.
• Staff were clear and knowledgeable about their lead roles and responsibilities.
• Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
• Patients reported difficulties accessing care and treatment in a timely way. The practice was trying to address this. However, there was no evidence of management oversight and monitoring to demonstrate if progress was being made to improve access for their patients.
• There were 142 patients registered as carers at the practice. This represented approximately 2.6% of the practice population.
• The way the practice was led and managed promoted an inclusive culture where staff could speak openly, access opportunities for personal development and be involved in the delivery of high-quality, person-centred care.
• Demonstrate through active reviews and monitoring improvements in patient access to the practice.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Record the day of the week that Methotrexate should be taken on the prescription as recommended by best practice guidance.
• Continue to develop and improve the recruitment processes and standard of staff documentation held.
• Provide patients with information on how to escalate complaints if required.
• Document and analyse the outcome of fire drills.

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 Hospitals and Interim Chief Inspector of Primary Medical Services