Ley Hill Health Centre

Updated 3 February 2023

Ley Hill Health Centre is located in the Northfield area of Birmingham at:

Ley Hill Health Centre

101 Holloway

Northfield

Birmingham

B31 1TR

The provider is registered with Care Quality Commission (CQC) to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Birmingham and Solihull Integrated Care Board (ICB) Integrated Care System (ICS) and provides services to patients under the terms of a general medical services (GMS) contract. This is a contract between general practices as independent contractors and NHS England to provide general medical services to its patient population of approximately 2,810.

The practice is part of a wider primary care network (PCN) of GP practices called South Birmingham PCN. A PCN is a wider network of GP practices that work together to address local priorities in patient care.

Information published by Public Health England shows that deprivation within the practice population group is in the first decile (one of 10). The lower the decile, the more deprived the practice population is relative to others. The age distribution of the practice population is mainly children, young people and people of working age. There is a similar number of male patients and female patients registered at the practice.

The practice clinical team consists of two male GPs who work the equivalent of 12 sessions per week, an advanced nurse practitioner and a practice nurse both of whom work part time. The practice also has the support of a clinical pharmacist and paramedic through the primary care network. The clinical staff are supported by a practice manager, business manager and administration, secretarial and reception staff. Staff are employed either full or part time hours to meet the needs of patients.

The practice is open between 8am and 6.30pm Monday to Friday. Patients are offered different types of appointments, dependent on need and clinical triage assessments between the hours of 9am and 5pm. When the practice is closed extended hours access is provided locally through the PCN local hub arrangements, where late evening, weekend and public holiday appointments are available. Out of hours services are provided by NHS 111.

Updated 3 February 2023

We carried out an announced comprehensive inspection) at Ley Hill Health Centre on 8 December 2022. Overall, the practice is rated as good.

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

This is the first inspection following the registration of Ley Hill Health Centre with new providers.

The full reports for previous inspections carried out under the previous registered providers for the location previously called Ley Hill Surgery can be found by selecting the ‘all reports’ link for Ley Hill Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

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 clinical interviews.
• 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.

We found that:

• Staff files were not organised to make ensure recruitment records were easily accessible and there were gaps in the completeness of information in the files.
• The immunisation status of some non-clinical staff was not available and risk assessments were not sufficiently detailed to demonstrate how any level of risk would be mitigated.
• The premises were visibly clean and tidy. An infection control lead was in place to ensure guidelines were being followed.
• Risk management processes were in place and risk assessments had been completed. this included fire safety and a range of health and safety assessments.
• The practice had a system in place for the actioning of significant events and incidents.
• We found limited documentation detailing the content and outcome of medicine reviews.
• Regular formal supervision was not carried out to monitor the prescribing practices of non-medical prescribers.
• The practice had management oversight of staff qualifications and training.
• Staff were clear and knowledgeable about their lead roles and responsibilities.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There was poor uptake of preventative treatments and screening procedures by patients. This was particularly in the areas of childhood immunisations and cervical screening.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
• The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centred care.

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

• Improve the standard and order of staff documentation held.
• Provide evidence that staff vaccination and immunity for potential health care acquired infections are recorded or risk assessed for all staff.
• Continue to promote and explore ways to improve the uptake of childhood immunisations and cervical screening.
• Implement systems for the ongoing monitoring and review of the completeness of documentation and updating of patient records following clinical and medicine reviews.
• Continue to proactively identify carers so that they can be supported to access services available to them.
• Introduce a formal system for the supervision of non-medical prescribers.

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