The Care Quality Commission
  • Doctor
  • GP practice

Clifton Medical Centre

Overall: Requires improvement read more about inspection ratings

Clifton Lane, West Bromwich, West Midlands, B71 3AS (0121) 588 7989

Provided and run by:
Clifton Medical Centre

All Inspections

12 October 2022

During a routine inspection

We carried out an announced comprehensive inspection at Clifton Medical Centre between the 27 September 2022 and 12 October 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are as follows:

Safe - requires improvement

Effective - good

Caring - requires improvement

Responsive - requires improvement

Well-led - good

Following our previous inspection in May 2021, the practice was rated requires improvement for the effective and caring key questions and therefore rated requires improvement overall. The practice was rated good for the safe, responsive and well-led key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Clifton Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive inspection to follow up on issues raised at our May 2021 inspection, in line with our inspection priorities.

The focus of inspection included:

  • All key questions
  • Any breaches of regulations or ‘shoulds’ identified in the previous inspection

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 short 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 found that:

  • Since our previous inspection the practice had continued to embed effective systems to keep patients safe and protected them from avoidable harm. This included the management of safeguarding concerns, recruitment process, safety alerts and patients on high-risk medicines. However, we also identified some areas where continued improvements were needed.
  • We found the premises were well maintained and infection prevention and control (IPC) measures were in place.
  • Our clinical searches found appropriate management of patients’ medicines. However, we found vaccines that were out of date. An investigation following the inspection identified no harm as a result.
  • Incidents and complaints were used to support learning and improvement.
  • Patients received effective care and treatment that met their needs. Our clinical searches found patients received appropriate follow up for their long-term conditions and improvements in outcome data.
  • The practice was able to demonstrate quality improvement activity was undertaken.
  • There was a high uptake of the practice’s mandatory staff training and the practice was able to demonstrate how it assured itself of the competence of staff in advanced roles.
  • Patient feedback on the service was mixed. Results from the latest GP national patient survey in relation to questions about patient experience and access were below local and national averages. There was limited evidence to show what action was being taken to address this.
  • The practice demonstrated that changes in the leadership and governance had led to improvements to support the delivery of high-quality person-centred care.

We found a breach of regulations. The provider must:

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

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

  • Include all household members in safeguarding alerts, such as parents, guardians and partners.
  • Address any issues identified during our clinical searches of medicines and long-term conditions that require follow up. Including recording day of week when prescribing a specific Disease-modifying anti-rheumatic drug (DMARD), issuing steroid cards where appropriate and ensuring all DNACPR decisions are fully recorded.
  • Conduct appropriate risk assessments for all staff whose immunisation status is not in line with recommended government guidance and take appropriate action where needed.
  • Continue to improve the uptake of child immunisations and cancer screening.
  • Update whistleblowing policy to ensure it is conducive with supporting staff to raise concerns.
  • Improve action plan to address decline in patient satisfaction of the service.

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

13 May 2021 to 21 May 2021

During a routine inspection

We carried out an announced inspection at Clifton Medical Centre between 13 to 21 May 2021. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Good

Effective – Requires Improvement

Caring – Requires Improvement

Responsive - Good

Well-led - Good

Following our previous inspection on 19 December 2019, the practice was rated Inadequate overall and for all key questions, except for providing caring services which was rated as requires improvement and placed into special measures. A further inspection was carried out in January 2020 and a GP Focussed Inspection Pilot (GPFIP) between 14 September 2020 and the 2 October 2020 was also carried out to check what improvements had been made.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Clifton Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on any breaches of regulations and ‘shoulds’ identified in the previous inspection.

How we carried out the inspection/review

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:

  • 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 shortened 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 Requires Improvement overall and requires improvement for all population groups, except for older people and people whose circumstances make them vulnerable which we have rated as good.

We found that:

  • The practice had implemented effective systems to ensure care was provided in a way that patients safe and protected them from avoidable harm. This included safeguarding arrangements, recruitment processes and the management of medicines.
  • The practice had strengthened their management of risk and we found infection control processes in place to ensure the safety of staff and patients, and a review of the risks in relation to the premises had been completed with an action plan in place to mitigate any future risks.
  • The practice had implemented a range of processes to improve and strengthen their systems. Continuous monitoring of practice procedures, clinical outcomes, clinical registers and staff training was now in place to ensure improvements were maintained.
  • Regular audits had been introduced to monitor quality improvement and ensure the information that was held for each patient was accurate.
  • We found significant improvements in the management of patients’ care and treatment. This included the appropriate monitoring of patients with long term conditions, the prescribing of medicines and the review of patients on high risk medicines.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. To reduce the risk of spreading the infection, patients who required a face to face appointment were seen at the amber site at Stone Cross Medical Centre.
  • Governance arrangements had been strengthened to ensure risks to patients were considered, managed and mitigated appropriately.
  • The practice had implemented a system of peer review for the clinical team. On reviewing a sample of patient records we found prescribing decisions were in line with recognised guidance and consultations contained relevant information.

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

  • Continue to encourage patients to attend cervical screening appointments.
  • Take action to improve the uptake of childhood immunisations.
  • Implement stronger systems to ensure DNACPR information is recorded appropriately.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care