Your Health Partnership (YHP) Also known as YHP-Regis Medical Centre

Updated 19 December 2022

Your Health Partnership (YHP) has a main practice, also the registered location with CQC, and is located in Rowley Regis at: Regis Medical Centre, Darby St, Rowley Regis B65 0BA.

The practice has 5 branch surgeries:

Lyndon Primary Care Centre, Sandwell Hospital, Lower Lyndon, B71 4HJ.

Mace Street Clinic, Mace St, Old Hill, Cradley Heath B64 6HP.

Oakham Surgery, 213 Regent Rd, Tividale, Oldbury B69 1RZ

Rowley Village Surgery, 91 Rowley Village, Rowley Regis, B65 9EN

Whiteheath Medical Centre, Badsey Rd, Oldbury B69 1EJ

As part of this inspection, we visited the main practice and the branch practice at Lyndon Primary Care Centre.

The provider Sandwell and West Birmingham Hospitals NHS Trust is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury and surgical procedures These are delivered from all sites except for surgical procedures, which is delivered form the main practice Regis Medical Centre and the branch practice Lyndon Primary Care Centre.

The practice is situated within the NHS Black Country Integrated Care Board (ICB) and delivers General Medical Services (GMS) a contract held with NHS England.

The practice is part of a wider network of GP practices called the Your Health Partnership Primary care network (YHP PCN).

Information published by Public Health England 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 8% Asian, 87% White, 2% Black, 2% Mixed, and 1% Other.

The PCN sits within the Primary Care Community Therapies group within the Trust. The provider has appointed a senior management team to manage the day to day running of this practice along with other practices that are part of the YHP PCN.

The senior management team is made up of a lead GP, a lead for quality and safety, head of nursing, clinical director for the PCN, directorate lead for the PCN, lead for patient engagement, a business manager, head of acute clinical service and head of finance.

All staff employed by the provider work at this practice as well as the other practices within the PCN.

For all practices with the PCN there is a team of 30 salaried GPs, 20 nurses and 8 advanced clinical practitioners (ACPs) and 7 healthcare assistants. There is a home visiting team, and a team that provides support to care homes. There were 6 pharmacists and 2 pharmacy technicians and a team of social prescribers and 6 physicians associates.

Clinical staff are supported at the practice by a team of reception and administration staff.

Each of the practices have a non-clinical lead (outlet lead), who staff can escalate concerns to.

The practice is open between 8am to 6.30pm 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 locally by practices within the PCN, where late evening and weekend appointments are available. Out of hours services are provided by 111.

Patients can call the practice between 8am and 8pm Monday to Friday , calls are managed by non-clinical staff working in the contact centre.

The provider introduced a new appointment booking system in September 2022. Patients have to submit a request online including details of their reason for appointment, preferred practice and clinician and preferred method of appointment. If patients are unable to submit this request, staff are able to do this for patients either face to face or on the telephone.

Appointment requests can be made while the practice is open and are triaged by a clinician and then prioritised in terms of urgency. Requests are either dealt with at the time if the clinician is able to or an appointment is arranged.

See the practice website yhp.org.uk for opening times for each practice.

Updated 19 December 2022

We carried out an announced comprehensive inspection at Your Health Partnership between 11 and 28 October 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective - requires improvement.

Caring – good.

Responsive - requires improvement.

Well-led - requires improvement.

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and to provide a rating for the service. The practice had not been inspected before under the current provider registration.

This was a comprehensive inspection and included all 5 key questions, to see if safe, effective, caring, responsive and well-led services were being provided.

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 and focus group interviews using video conferencing. Interviews were held between 11 and 28 October 2022.
• 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 before and after the site visit.
• A shorter site visit on 18 October 2022.

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:

• Systems and processes that were implemented to keep patients and staff safe and protected from avoidable harm required improvement.
• Patients did not always receive effective care and treatment that met their needs.
• Not all staff had completed required training that was relevant for their role, including safeguarding and basic life support training.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could not always access care and treatment in a timely way. The senior management team were taking appropriate action to improve access for patients.
• Whilst governance processes required improvement, the senior leadership team demonstrated that they understood the challenges of delivering high-quality, person-centre care.
• The practice was part of a wider organisation that promoted joined up working between primary and secondary care to improve services for its patient population.

We found 2 breaches of regulations. The provider must:

• 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 provider should:

• Continue to improve uptake with children’s immunisations and cervical cancer screening.
• Take action to improve policies such as management of clinical waste and demonstrate they are working as intended.
• Take steps to ensure all staff have access to safeguarding information as relevant for their role.
• Take action to review patients with long term conditions and/or learning disabilities where reviews are indicated or records have been coded incorrectly.
• Continue to monitor and respond to patient feedback to improve access.
• Take action to be fully compliant with the accessible information standard.

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.