Background to this inspection
Updated
12 November 2019
Drs Yap, Hughes and Michael’s practice (also known as Maypole Health Centre) is part of the NHS Birmingham and Solihull Clinical Commissioning Group (CCG). A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services.
Drs Yap, Hughes and Michael is registered with the Care Quality Commission to provide primary medical services and carry out the following regulated activities: diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury. NHS services are provided through a General Medical Services (GMS) contract to approximately 4659 patients. A GMS contract ensures practices provide essential services for people who are sick as well as, for example, chronic disease management and end of life care and is a nationally agreed contract. The practice also provides some enhanced services such as childhood vaccination.
The practice is located in a purpose-built health centre which it shares with one other practice. Based on data available from Public Health England, deprivation in the area served is below the national average.
The practice has three GP partners (two male and one female). Other practice staff consist of a nurse practitioner, a practice manager and a team of administrative / reception staff. The practice is a designated training practice for trainee GPs. These are qualified doctors who are learning the role of a GP.
The practice is open 8.30am to 6.15pm on Monday, Tuesday, Wednesday and Friday, closing an hour for lunchtime between 12.30pm and 1.30pm. On a Thursday the practice is open 8.30am to 1pm. Appointments are generally available between 8.30am to 11am then 2pm to 5.30pm, except on Thursday when the practice is closed in the afternoon and appointments are only available between 8.30am to 11am. The practice provides an extended access service as part of a joint working arrangement with other local practices within the Primary Care network. Extended access appointments are booked by patients through their GP practice and patients are seen at Oakwood Surgery, Sparkhill, Monday to Friday, and on a Saturday and Sunday. Patients are also seen at Druids Heath Surgery on a Saturday. Appointments are available Monday to Friday 6.30pm to 8pm and Saturday and Sunday between 9am to 1pm.
When the practice is closed during core hours and out of hours, cover is provided by a GP service contracted by the practice. The answerphone message when the practice is closed provides details on how to contact the service provider.
The practice was previously inspected in May 2015 and rated good overall.
Updated
12 November 2019
We carried out an announced focused inspection at Drs Yap, Hughes and Michael on 11 September 2019, following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
- Safe
- Effective
- Responsive
- Well-led
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
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 and well led services because:
- There were some systems and processes in place to keep people safe. However, these were not always identified, sufficiently well managed or embedded to ensure their effectiveness.
- There was a lack of effective leadership oversight to ensure good governance. The practice did not always have clear and effective processes for managing risks, issues and performance.
We rated the practice as good for providing effective and responsive services because:
- The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was consistently positive. This included the results of the national GP survey, CQC comment cards and patient interviews.
- Overall, patients could access care and treatment in a timely way. Some patients reported that access to appointments was difficult, the practice was taking action to address this.
The areas where the provider must make improvements are:
- 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 to promote and explore ways to improve the uptake of cancer screening.
- Continue to explore ways to improve access for patients.
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