The Care Quality Commission
  • Doctor
  • GP practice

Archived: Reservoir Road Surgery

Overall: Good read more about inspection ratings

192 Reservoir Road, Erdington, Birmingham, West Midlands, B23 6DJ (0121) 465 2950

Provided and run by:
Reservoir Road Surgery

Important: The provider of this service changed. See new profile

All Inspections

5 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Reservoir Road Surgery on 15 June 2016. The overall rating for the practice was requires improvement. This was because arrangements for preventing the spread of infection, systems for monitoring and improving the quality of service including patient outcomes required improvement. Governance arrangements including systems for assessing and monitoring risks also required improvement. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Reservoir Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 5 September 2017; to confirm that the practice had carried out their plan to meet the required improvements in relation to the breaches in regulations that we identified during our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. Overall, the practice is rated as good.

Our key findings were as follows:

  • A system was in place for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. However, records we viewed during our inspection showed limited evidence of communication with complainants and shared learning following safety incidents.

  • The practice had clearly defined and embedded systems to minimise risks to patient safety. For example, effective systems were in place for receiving and acting on national alerts from the Medical and Healthcare products Regulatory Agency (MHRA).

  • Staff were aware of current evidence based guidance. Staff received training in most areas to provide them with the skills and knowledge to deliver effective care and treatment.
  • Data from the 2015/16 Quality and Outcomes Framework showed patient outcomes were at or above average compared to the national average.

  • The practice carried out a number of quality improvement activities to monitor performance such as clinical audits. These demonstrated areas of improvement in the delivery of the service

  • Results from the July 2017 national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

  • Information about services and how to complain was available. We saw examples where improvements were made to the quality of care as a result of complaints and concerns. However, staff were not able to demonstrate that all complaints were followed up with an acknowledgment or finalisation letter.
  • Feedback from patients received through the completed Care Quality Commission comment cards and from members of the Patient Participation Group showed that patients 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 clear vision and strategy which had been produced with the involvement of practice staff and was regularly reviewed and discussed during meetings.
  • The practice had visible clinical and managerial leadership and governance arrangements. However, oversight of some governance arrangements such as management of complaints, significant events and monitoring of training needs was not effective.

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

Importantly, the provider must:

  • Ensure that persons employed in the provision of a regulated activity receive appropriate training and professional development as necessary to enable them to effectively carry out the duties they were employed to perform.

In addition the provider should:

  • Ensure effective recording of learning outcomes to ensure opportunities to learn from incidents are maximised.

  • Ensure systems and processes are established and operated effectively.

  • Continue to encourage patients to attend national screening programmes such as breast cancer screening.

  • Continue exploring and establishing effective methods to identify carers in order to provide further support where needed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Reservoir Road Surgery on 15 June 2016. Overall the practice is rated as requires improvement.

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

  • Most risks to patients were assessed and well managed. However, some systems and processes were not in place to keep patients safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control had not been monitored or completed.
  • There was a process for reporting incidents, near misses and concerns but there was insufficient evidence of learning and communication with all staff.
  • Data from the Quality and Outcomes Framework (QOF) showed the practice was an outlier for clinical targets in coronary heart disease (CHD) prevalence, diabetes, hypertension, mental health and cervical screening. We saw no evidence that audits were driving improvements to patient outcomes in these areas.
  • Patients we spoke with and the comment cards we received were positive about their interactions with staff and said they were treated with compassion and dignity. The national patient survey results indicated that patient satisfaction with GP and nurse consultations was generally above local and national averages.
  • The appointment systems were not working well so patients did not receive timely care when they needed it. The practice had installed a new telephone system to improve phone access although the impact of this had not yet been assessed.
  • Information about how to complain was available and some improvements were made to the quality of care as a result of complaints and concerns. However, learning from complaints was not effective.
  • The practice had a number of policies and procedures to govern activity, but not all had become embedded.
  • The practice did not proactively seek feedback from staff and patients and a patient participation group had not become established.
  • The practice had insufficient leadership capacity and management support to properly establish formal governance arrangements and have robust oversight of practice processes.

The areas where the provider must make improvements are:

  • Take action to address identified concerns with infection prevention and control practice.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Implement systems to assess, monitor and improve the quality of the service and patient outcomes. For example, take action to deliver improvements in identified areas such as reviews of long term conditions and cytology screening.
  • Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
  • Ensure there is sufficient leadership capacity and management support to effectively deliver improvements.

The areas where the provider should make improvement are:

  • Strengthen the processes for sharing significant events, incidents, safety alerts and complaints to ensure lessons are learned, properly shared and where appropriate further risks are mitigated.
  • Review procedures to ensure effective documentation and organisation of information to enable easier monitoring processes.
  • Consider a more robust monitoring process for staff training and ensure action is taken when training is overdue.
  • Further progress the steps taken to improve the process for making appointments, the availability of non-urgent appointments and to reduce appointment waiting times.
  • Consider the benefits of actively using the carers register to support and improve patient care and welfare.
  • Take action to progress steps to establish a patient participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice