The Care Quality Commission
  • Doctor
  • GP practice

Glebefields Surgery

Overall: Good read more about inspection ratings

St Marks Road, Tipton, West Midlands, DY4 0SN (0121) 530 8040

Provided and run by:
Dr Raymond Sullivan

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Glebefields Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Glebefields Surgery, you can give feedback on this service.

21 December 2019

During an annual regulatory review

We reviewed the information available to us about Glebefields Surgery on 21 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

13 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We first inspected Dr Raymond Sullivan’s surgery on 16 November 2016 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Ray Sullivan’s surgery on our website at www.cqc.org.uk. During the inspection, we found the practice was in breach of legal requirements this was because appropriate processes were not in place to mitigate risks in relation to the safety and quality of the services offered. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.

This inspection was an announced focussed inspection, carried out on 13 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall we found improvements had been made to the concerns raised at the previous inspection and as a result of our inspection findings the practice is now rated as Good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Since the previous inspection, an effective system had been implemented to ensure all incidents were acted on and learning was shared with all staff members. The practice carried out an analysis of each event with a documented action plan.
  • We found that the practice had reviewed their processes for receiving safety alerts and all alerts were actioned upon receipt and actions taken were recorded and discussed as part of the clinical team meetings, which were held every week.
  • At this inspection, we saw a programme of clinical audits had been implemented to monitor patients’ outcomes and improve the quality of care provided.
  • We saw evidence to confirm that staff had received the appropriate checks with the disclosure and barring service (DBS).
  • At our previous inspection we found the practice did not have effective systems and processes to monitor patients on high risk medicines. This risk had been mitigated with the implementation of guidelines to monitor patients on high risk medicines, the support of a clinical pharmacist and a review of all patients to ensure they were receiving the appropriate care.
  • The practice had a number of governance policies and procedures in place, which had been reviewed and updated. The governance arrangements to assess and monitor the

quality of services showed improved outcome with a schedule of regular governance meetings in place since the last inspection in November 2016. This included monthly team meetings and weekly clinical meetings.

  • At this inspection we saw evidence that an IT training needs analysis had been completed and identified gaps in staff’s IT knowledge had been actioned.
  • The practice proactively sought feedback from staff and patients, however at our previous inspection, we were told there was a patient participation group (PPG) but they did not meet regularly and were not actively involved in practice developments. At this inspection, the practice told us they had tried to encourage patients to join the group and had sought support from the clinical commissioning group (CCG). A virtual group had been planned and the practice were still looking at this possibility. A PPG meeting had been arranged for the end of October 2017 which was on display in the waiting room to advise patients.
  • The practice had achieved in cervical screening with 91% of patients having had a cervical screening test in the past five years, the practice had been asked to participate in a cervical screening workshop for primary care providers by Public Health England to share good practice and educate primary care about strategies to increase cervical screening coverage.
  • Following our previous inspection, the practice had recruited a clinical pharmacist to support the GPs in monitoring prescribing and effective auditing of medicines.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16th November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Glebefields Surgery on 16November 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough to identify trends and share learning.

  • Systems and processes were not robust to keep patients safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and arrangements were not in place to review patients on high risk medicines.
  • Patient outcomes were hard to identify as audits did not demonstrate quality improvement.
  • The national GP patient survey results were published in July 2016. The results showed the practice was performing above national averages. 282 survey forms were distributed and 120 were returned. This represented 2.8% of the practice’s patient list.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about the services provided and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had a leadership structure, however, there was insufficient leadership capacity and formal governance arrangements to monitor the quality of the service.
  • The practice had a number of policies and procedures to govern activity, but some had not been reviewed to ensure they were up to date.

The areas where the provider must make improvements are:

  • Have effective systems in place to investigate all incidents including significant events, share the lessons learned with all staff and monitor any emerging trends which require service improvement.

  • Ensure recruitment procedures are robust and include all necessary pre-employment checks for staff including DBS checks.

  • Carry out completed clinical audits to demonstrate improvementto patient outcomes.

  • Put a system in place to demonstrate that following receipt of a safety or medecine alert appropriate action was taken.

  • Review governance arrangements to ensure oversight of performance and make quality improvements as appropriate. Review and update procedures and guidance such as the infection control procedure.

In addition the provider should:

  • Ensure all staff have the necessary IT skills to use the practice computer system effectively.
  • Ensure consent forms clearly document the risks and benefits to patients for specific care and treatment.
  • Have formal arrangements in place for the patient participation group (PPG) to contribute to the development of the practice to improve patients experience of the service.

  • Update the practice websitewhich promoted an open patient list meaning that new patients could register with the practice. However due to the increasing demand for the service, the only new patients currently being registered were partners or children of those already registered.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice