Background to this inspection
Updated
8 August 2018
Dr Yosry Gabriel is the registered provider of Baldwins Lane Surgery. The practice is situated in a converted two-story building, which was previously a residential building. All clinical rooms are on the ground floor. The first floor is used by administration staff. The surgery address is 265 Baldwins Lane, Birmingham, West Midlands, B28 0RF. More information about the practice can be found on their website: www.baldwinslanesurgery.info.
The practice is registered with CQC to provide the following regulated activities:
- Diagnostic and screening procedures
- Family planning
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
The practice provides GP services to approximately 3700 NHS patients.
Based on 2015 data available from Public Health England, the levels of deprivation in the area served by Baldwins Lane Surgery are less than national averages, ranked at seven out of 10, with one being the most deprived and 10 being the least deprived. (Deprivation covers a broad range of issues and refers to unmet needs caused by a lack of resources of all kinds, not just financial).
Based on data 2015 from Public Health England, 25% of people in the practice area are from black and minority ethnic groups.
Limited on-site parking is available. The surgery does not have automatic entrance doors; however, staff attend to patients when they require assistance to access the practice.
The practice employs one male lead GP, three part time locum GPs (two female and one male), two part time practice nurses, and a phlebotomist. At the time of our inspection, the practice had a vacancy for a healthcare assistant.
Clinical staff are supported by a practice manager, a business support manager and reception and administration staff.
The practice is an approved training practice providing training to medical students, however did not have any trainee doctors at the time of inspection.
The practice is open between 8am and 6.30pm Mondays, Tuesdays and Fridays; 8am to 1pm Wednesdays, and 8am to 7.30pm on Thursdays.
Morning GP consulting hours are from 9am to 12 noon Mondays to Fridays. Afternoon consulting hours are from 3pm to 6pm daily, except for Wednesdays where the surgery closes at 12 noon. Extended consulting hours are provided on Thursdays from 6pm to 7.20pm.
During the surgeries in hour’s closure on Wednesdays from 12 noon to 7pm, services are provided by Birmingham and District General Practitioner Emergency Rooms (BADGER) medical services. The practice has opted out of providing cover to patients in their out of hours period including weekends and Bank Holidays. During this time, services are provided by NHS 111.
Updated
8 August 2018
This practice was previously inspected in October 2017 and rated as Requires improvement overall.
This practice is now rated as Good overall.
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Baldwins Lane Surgery on 4 July 2018 to follow up on breaches of regulations we identified during our previous inspection in October 2017.
At this inspection we found:
- The practice had taken appropriate action following our previous inspection in October 2017 to ensure they were complying with regulations where we had previously identified breaches.
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels.
We saw one area of outstanding practice:
The practice had discussed as a team they would like to improve their numbers of patients attending screening for Abdominal aortic aneurysm (AAA). The practice invited all male patients registered with them, over the age of 65, who had previously not been invited, or had been invited and not attended, for screening of Abdominal aortic aneurysm (AAA). In total the practice invited 228 male patients to attend. Of the patients invited, 79 attended and five were diagnosed with an abnormal aorta. All identified patients were followed up appropriately. The practice was contacted by the screening team at a local NHS trust and asked if they would share the letter they had used to invite patients as it was felt that other GP practices who struggled with patients attending screening appointments would benefit from using the letter.
The areas where the provider should make improvements are:
- The provider should ensure all actions from their fire risk assessment are completed as planned.
- The provider should continue to improve processes to ensure all safety checks are documented in line with practice policies and procedures.
- The provider should ensure all relevant staff are aware of the practice’s policy for patient specific directives, and take action to ensure it is adhered to and operated effectively when a healthcare assistant is employed.
- The provider should continue to take action to improve uptake of children’s’ vaccinations.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.