The Care Quality Commission
  • Doctor
  • GP practice

Oakwood Surgery

Overall: Good read more about inspection ratings

856 Stratford Road, Sparkhill, Birmingham, West Midlands, B11 4BW 0845 073 0397

Provided and run by:
Oakwood Surgery

All Inspections

28 April 2022

During a routine inspection

We carried out an announced comprehensive inspection at Oakwood Surgery on 28 April 2022. We have rated the practice as requires improvement for providing effective services. Overall, the practice is rated as good.

Set out the ratings for each key question

Safe – Good

Effective – Requires Improvement

Caring – Good

Responsive – Good

Well-led – Good

We previously carried out an announced comprehensive inspection at Oakwood Surgery on 27 October 2015, 9 March 2017, 22 January 2021 and 25 August 2021 as part of our inspection programme. At the inspection in August 2021 the practice was rated as requires improvement for providing effective and well led services, with an overall rating of requires improvement.

We carried out an announced focused inspection 25 August 2021 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 22 January 2021.

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

This inspection review was a comprehensive inspection to review whether the practice had addressed the requirements made following the review in August 2021. This inspection included a site visit to follow up on:

  • Key questions relating to the Safe, Effective and Well Led domains.
  • Areas followed up including any breaches of regulations or ‘shoulds’ identified in 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 was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing the findings with the provider.
  • 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 have rated this practice as Good overall

We found that:

  • The practice provided care in a way that mainly kept patients safe and protected them from avoidable harm.
  • Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
  • The practice had a system for recording and disseminating actions carried out as a result of significant events.
  • The practice had taken appropriate action to support and protect patients identified as at risk from harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had management oversight of staff qualifications and training.
  • Staff were clear and knowledgeable about their lead roles and responsibilities.
  • Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
  • The practice had reviewed and implemented systems to address patients concerns about access to the practice for timely care and treatment.
  • There continued to be a poor uptake by patients of preventative treatments and screening procedures. This was particularly in the areas of childhood immunisations and cervical screening.
  • There were 138 patients registered as carers at the practice. This represented approximately 1.3% of the practice population.
  • 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.
  • The practice considered patient wellbeing. For example, a policy was in place to support staff that were carers.

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

  • Continue to promote and explore ways to improve the uptake of childhood immunisations and cervical screening.
  • Introduce systems to review and monitor the impact of any actions put in place to improve the uptake of preventative treatments and screening.
  • Continue to review and monitor that all tests are completed and recorded for patients prescribed high risk medicines.
  • Continue to review, monitor and improve patient access to the practice.
  • Continue to proactively identify carers so that they can be supported to access services available to them.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

25 August 2021

During an inspection looking at part of the service

We carried out an announced inspection at Oakwood Surgery on 25 August 2021. Overall, the practice continues to be rated as requires improvement.

Set out the ratings for each key question

Safe - Good

Effective – Requires improvement

Well-led – Requires improvement

Following our previous inspection, on 22 January 2020 the practice was rated requires improvement for safe, effective, and well-led key and rated requires improvement overall.

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

Why we carried out this inspection

This was a focused inspection to follow up on:

  • Safe, effective, and well-led key questions
  • Breaches of regulations as well as ‘shoulds’ identified in previous inspection
  • Ratings carried forward from 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:

  • Conducting staff interviews using video conferencing
  • 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 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 have rated this practice as Requires improvement overall and good for all population groups; except Families, children and young people and working age people (including those recently retired and students) which we rated requires improvement.

We found that:

  • The practice provided care in a way that mainly kept patients safe and protected them from avoidable harm.
  • Staff demonstrated awareness of actions required if they suspected safeguarding concerns. Since our previous inspection, the practice took action to gain assurance that clinical staff who were not directly employed by the practice had completed safeguarding training.
  • Patients received effective care and treatment that mainly met their needs. In particular, since our last inspection, the provider implemented system’s which provided assurance that care was managed effectively when care was shared with other health care providers.
  • The practice had a system for recording and disseminating actions carried out as a result of significant events. Records showed incidents were being discussed during clinical meetings; and staff were routinely completing the practice significant events log demonstrating thorough investigations to establish root causes.
  • Quality Outcome Framework (QoF) clinical indicators for the 2019/20 QoF year were in line with local and national averages.
  • The management team were aware of comments and feedback placed on various online platforms and respond to these comments. To improve patient experience; members of the management team observed reception staff and provided feedback in regard to allowing patients time to speak and explain their issues. The practice also made changes to the phone system and increased the number of staff taking calls during busy periods.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing effective and well-led services because:

  • The practice was on an ongoing journey to further strengthen and embedded systems and process. However, there were areas where quality improvement activities required further strengthening, such as oversight of medicine management as well as ongoing management of patients diagnosed with a long-term condition.
  • Whilst clinical leads explained carrying out reviews of non-medical prescribers prescribing practice and discussions to support prescribers with clinical decisions; there were no documents or evidence provided to demonstrate this.
  • National screening programs such as cervical cancer screening and the uptake of childhood immunisations were below target. The practice demonstrated awareness of this and demonstrated actions taken since or previous inspection, as well as during the national pandemic to improve uptake.
  • Clinical governance arrangements had been strengthened; in particular, sub teams were developed to address areas where performance showed negative variation. However, changes were not yet operating effectively in areas such as medicines management.
  • The way the practice was led and managed mainly promoted the delivery of high-quality, care. The provider made changes to the governance arrangements since our previous inspection and was on a journey to further strengthen governance arrangements. However, there were areas where changes were not entirely embedded and operating effectively.

We found a breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

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

  • Continue taking action to improve the uptake of childhood immunisations and cervical screening.
  • Take action to ensure a documented approach which demonstrates regular reviews of non-medical prescribers prescribing practice; supported by clinical supervision and or peer reviews.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Oakwood Surgery on 22 January 2020 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions.

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well-led?

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.

We rated the practice as requires improvement for providing safe, effective and well-led services because:

  • The practice had systems and processes to keep patients safe and protected them from avoidable harm. However, systems did not include enabling identification of vulnerable adults on the clinical system and safeguarding discussions with external agencies were not added to patients’ clinical records.
  • Staff demonstrated awareness of actions required if they suspected safeguarding concerns. However, the practice did not gain assurance that clinical staff who were not directly employed by the practice had completed safeguarding training.
  • The practice provided care in a way that mainly kept patients safe and protected them from avoidable harm. However, there were areas such as medicine management and arrangements for dealing with medical emergencies which exposed patients to the risk of potential harm.
  • Patients mainly received effective care and treatment that met their needs. However, the practice did not provide assurance that care was managed effectively when care was shared with other health care providers. There was limited evidence to demonstrate proactive use of care plans. Following our inspection, the provider submitted evidence which showed actions had been taken to ensure monitoring of patients’ health were carried out.
  • Quality Outcome Framework (QoF) clinical indicators were mainly in line with local and national averages. However, exception reporting for long-term conditions was above local and national averages. The practice had not audited the system to identify root causes.
  • The practice had a system for recording and disseminating actions carried out as a result of significant events. Records showed incidents were being discussed during clinical meetings; however, staff were not routinely completing the practice significant events log to demonstrate thorough investigations to establish root causes.
  • Oversight of clinical governance did not routinely support the delivery of safe and effective care. The clinical leadership team did not establish proactive measures to address areas where performance showed negative variation. There was a lack of meaningful clinical audits to demonstrate safe and effective management of patients care.
  • There were areas where oversight of the governance framework was not effective. In particular; systems to ensure training was completed at the appropriate level; risk assessments to mitigate potential risks were not routinely carried out.
  • There were roles and responsibilities to support the governance framework. However, some areas lacked effective oversight such as the monitoring of training, recording and investigating significant events as well as the accuracy of clinical record keeping.

These areas affected all population groups, so we rated all population groups as requires improvement overall.

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated the practice as good for providing caring and responsive services because:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice obtained feedback from various sources which included an active patient participation group (PPG) and actions were taken to improve patient satisfaction in areas such as appointment access and getting through to the practice by phone.
  • The practice had a vision and strategy to deliver care and treatment to their population group. Staff felt supported and able to raise concerns.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue taking action to improve the uptake of childhood immunisations and cervical screening.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

9 March 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Oakwood Surgery on 27 October 2015. The overall rating for the practice was good but rated as requires improvement for providing safe services.

We found the practice required improvement in this area due to breaches in regulations relating to safe care and treatment. This was because:

  • The practice did not ensure that all repeat prescriptions were re-authorised by clinicians.

  • The practice did not have robust arrangements in place to deal with foreseeable emergencies that may impact on the running of the practice.

The full comprehensive report on the October 2015 inspection can be found by selecting the ‘all reports’ link for Oakwood Surgery on our website at www.cqc.org.uk.

On 9 March 2017 we carried out a desk-based focus review to confirm that they had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27 October 2015. This report covers our findings in relation to those requirements.

Our key findings were as follows:

  • The practice no longer allowed administrative staff to reauthorise repeat prescriptions. All prescriptions were authorised by the GPs or advanced nurse prescribers. There was an electronic prescribing system in place and clinical prescribing staff had been trained to use this. The practice had implemented a detailed repeat prescribing policy and flowchart which formalised these arrangements.

  • The practice had put in place a detailed and comprehensive business continuity plan to assess and manage risks relating to health, safety and welfare of patients; and to address foreseeable emergencies that may impact on the running of the practice. The business plan had been shared with all staff. Copies of the plan and emergency contact numbers were kept off site.

The practice is now rated as good for providing safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Oakwood Surgery on 27 October 2015. Overall the practice is rated as good.

  • Our key findings across all the areas we inspected were as follows: The practice valued opportunities to learn and develop.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.

  • Risks to patients were assessed and well managed.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.

  • Staff had received training appropriate to their roles. For example as there was a high prevalence of diabetes one of the GP partners had completed the Warwick certificate in diabetes care.

  • Patients said they were treated with kindness and compassion. Many of the patients we spoke with had been with the practice for many years.

  • Information about services and how to complain was available and easy to understand (including in different languages such as Arabic).

  • Patients told us that there was continuity of care, with urgent appointments available the same day. Patient reviews were routinely carried out. The care home managers spoke very highly of the GPs at the practice.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Action the provider must take to improve:

  • Ensure that all repeat prescriptions are only reauthorised by clinicians.

  • Ensure that arrangements are in place to ensure the practice is able to deal with foreseeable emergencies that may impact on the running of the practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice