The Care Quality Commission
  • Doctor
  • GP practice

Archived: Wake Green Surgery

Overall: Inadequate read more about inspection ratings

7 Wake Green Road, Birmingham, West Midlands, B13 9HD (0121) 449 0300

Provided and run by:
Wake Green Surgery

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

All Inspections

16 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Wake Green Surgery on 17 August 2015. The overall rating for the practice at the time was requires improvement. We found breaches in relation to regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report on the Wake Green Surgery inspection can be found by selecting the ‘all reports’ link for Wake Green Surgery on our website at www.cqc.org.uk.

This inspection was undertaken to follow up progress made by the practice since the inspection on 17 August 2015. It was an announced comprehensive inspection on 16 December 2016. Overall the practice is now rated as inadequate.

Our key findings were as follows:

  • Although the practice had taken some action since our previous inspection we continued to identify issues relating to the provision of safe services. This included prescription safety and security, staffing arrangements and support and with the effective monitoring of safety arrangements.
  • There had been some improvements in the management of risks to patients although there was a lack of consistency in the effective assessment and monitoring of those risks.
  • Significant events and incidents were generally well managed but there was little evidence of shared learning with all staff and we saw evidence of opportunities for learning missed.
  • Staff made use of current evidence based guidance in the provision of care and had the skills, knowledge and experience to deliver effective care and treatment. However, it was difficult to ascertain the level of supervision and support that all staff had received as there was no formal system in place to monitor this and records seen were incomplete.
  • The practice did not always respond in a timely way to patient information received or when making referrals leading to potential delays in patients care and treatment.
  • Working relationships with health and social care professionals were in place to understand and meet the range and complexity of patients’ needs. However, health and social care professionals experienced a range of difficulties when working with the practice which impacted on patient care.
  • Patients said they were treated with compassion, dignity and respect. Results from the national GP patient survey showed patients rated the quality of consultations in line with others but slightly lower than others in relation to involvement in decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand. The practice responded to complaints in an open an honest way. However, we saw trends in the complaints that had not reviewed to identify where systems and processes may be improved.
  • Not all patients said they found it easy to make an appointment. The practice was taking action to try and improve access for patients.
  • The practice was equipped to treat patients and meet their needs.
  • The practice had no clear leadership structure and the practice was unable to demonstrate effective team working.
  • Systems in place for responding to feedback from staff and patients were not always effective.
  • The provider was aware of the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure the safety and security of prescription stationery in the practice and the management of uncollected prescriptions.
  • Ensure effective systems are in place for the timely management of patient information and referrals.
  • Ensure effective working arrangements with health and social care professionals.
  • Ensure effective governance arrangements to ensure risks are effectively assessed and monitored such as the cleaning of clinical equipment, carpets and curtains and for checking of defibrillator and the availability of safety information for the control of substances hazardous to health.
  • Ensure effective systems for managing incidents and significant events to ensure learning and to support safety improvements.
  • Ensure effective system are put place to respond to trends in incidents and complaints to support safety improvements and ensure learning.
  • Ensure appropriate information is available to verify the fitness of staff to work with vulnerable patients and others.

The areas where the provider should make improvement are:

  • Ensure all patients with a learning disability are offered an annual health review.
  • Review and take action to improve the induction and appraisal process for newly recruited staff.
  • Review how patient involvement in their care and treatment may be improved.
  • Continue to review and take action to improve patients access to appointments.
  • Ensure the practice website is updated to ensure accurate information about the complaints process is available.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

REQUIRES IMPROVEMENT

We carried out an announced comprehensive inspection at Wake Green Surgery on 17 August 2015. 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.

  • Systems and processes were not in place to keep patients and staff safe. For example, appropriate fire safety assessments had not taken place, risk assessments were not in place in respect of control of substances hazardous to health or legionella. Additionally, actions identified to address concerns with infection control practice did not have identified timelines for completion.

  • Monitoring processes were not sufficiently robust for example in alerting that annual medical equipment checks are due.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

  • Staff who acted as chaperones were trained for the role but had not completed a disclosure and barring check (DBS). In the absence of a DBS check, the risk assessments were not sufficiently detailed to provide assurances that risks to patients had been minimised.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Information about services and how to complain was available and patients we spoke with were aware of the process to follow.

  • Data showed patient outcomes were near the average for the locality with the exception of being able to see a preferred GP which was below average. The childhood immunisation rates for the practice were above CCG averages.

  • Urgent appointments were available on the day they were requested. However, patients said that they sometimes had to wait a long time for non-urgent appointments and that it was very difficult to get through to the practice when phoning to make an appointment. Results of the July 2015 national patient survey were aligned to this.

  • There was a clear leadership structure and staff felt supported by the GP partners. The practice had sought patient feedback from the PPG, some of which it had acted on. However, the practice had not proactively sought feedback from staff or patient perspectives from patients who were not part of the PPG.

The areas where the provider must make improvements are:

  • Ensure there are effective systems in place to identify, assess the quality of the service and manage risks in order to protect service users, and others, against the risks of inappropriate or unsafe care (by ensuring all risk assessments are in place such as in respect of control of substances hazardous to health, fire safety and legionella). Additionally, actions identified by the Fire Safety Officer must be completed to ensure the risks of fire are minimised.

  • Ensure that the business continuity plan contains sufficient details and that all staff are aware of its contents.

In addition the provider should:

  • Improve processes for making appointments, including addressing patient difficulties in getting through to the practice on the phone.
  • Ensure that the risk assessments of staff who carry out chaperoning without having gone DBS checks are sufficiently detailed to provide assurances that risks have been fully considered.
  • Ensure patient feedback which is not restricted to only those who are members of the patient participation group (PPG) and wider more proactive patient engagement takes place.
  • Ensure that ease of access for all patients has been considered for example for wheelchair users within the waiting area.
  • Ensure all staff are clear about who the infection control lead for the practice is, and that action identified to address concerns with infection prevention and control has clear timelines for completion.
  • Ensure the practice monitoring processes are sufficiently robust for example processes to alert the practice when annual medical equipment checks are due.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 November 2013

During a routine inspection

As part of our inspection we spoke with nine patients who used the service. This included two patients who were also members of the patient panel. We also spoke with nine clinical and administrative members of staff including the registered manager who was also one of the GP partners.

Patients spoken with were positive about with the care and treatment they received at the practice. Patients told us that they were treated with dignity and respect and that their health needs were kept under review. Comments received from patients included: 'I have been very happy with my care here'; 'I've always had a fairly good experience with it [the practice]' and 'They have a nice selection of doctors, I don't really mind who I see.'

There were good systems in place to ensure patients were protected from the risks associated with medicines. Two pharmacists were employed at the practice to support the GPs and help in the management of patients with complex needs relating to their medicines. Medicines were stored appropriately and patients on long term medication were kept under review.

Systems were in place to manage complaints received about the practice. We saw that complaints were handled appropriately and used to support learning and service improvement.

There were systems in place to reduce the risks and spread of infection. We saw there had been some recent refurbishment to the premises although further work was still needed.