The Care Quality Commission
  • Doctor
  • GP practice

The Limes Medical Centre

Overall: Good read more about inspection ratings

Cooksey Road, Small Heath, Birmingham, West Midlands, B10 0BS (0121) 772 0067

Provided and run by:
The Limes Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Limes Medical Centre 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 The Limes Medical Centre, you can give feedback on this service.

13 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Limes Medical Centre on 13 December 2019. 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:

  • Safe
  • Effective
  • Caring
  • Responsive
  • 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 good overall and good for all population groups, with the exception of the “working age” and “families, children and young people” population groups.

We rated the practice as requires improvement for providing effective services because;

  • The practice performed well in benchmarking results (QOF) in all areas except for childhood immunisations and cancer screening. In relation to childhood immunisations, the practice was unable to fully demonstrate that sufficient improvements had been made. In relation to cancer screening, the practice had taken action to address these. Although bowel cancer screening had improved, the practice could not yet demonstrate that breast and cervical screening uptake had improved. Following the inspection, the practice provided some unverified data that suggested that cervical screening was beginning to improve but was still below target.

We rated the practice as Good for providing safe, caring, responsive and well-led services because;

  • The practice had well established systems to keep patients safe from avoidable harm and safeguard them from abuse and improper treatment. The practice had a suite of risk assessments that were appropriately and meaningfully utilised to improve outcomes for patients.
  • Patient satisfaction on the national GP patient survey was lower than averages in a number of areas. The practice demonstrated that they had taken action to address these, for example, providing guidance for and facilitating discussions on consultation styles and providing training to ensure patients’ needs were met. The practice in-house survey demonstrated that patient satisfaction was improving.
  • In relation to access to care and treatment, the practice had taken a number of actions, including employing extra staff and putting in extra telephone lines and were able to demonstrate that patient satisfaction had improved as a result.
  • The practice leadership demonstrated the capacity and capability to provide high quality care and deliver appropriate services to their population group. They were visible and had a clear strategy to ensure that outcomes for patients continued to improve.

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

  • Ensure that all risks relating to ongoing DBS checks have been considered.
  • Establish a formal system of supervision for non-medical prescribers.
  • Continue to ensure that improvements are made to cancer screening uptake figures.
  • Continue to ensure that improvements are made to childhood immunisation uptake figures.
  • Continue to ensure that patient satisfaction improves, with regular 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

7th March 2018

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection at The Limes Medical Centre on 12 January 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for The Limes Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 March 2018 to confirm that the practice had carried out improvements in relation to the areas of improvements we identified in our previous inspection on 12 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows;

  • Significant events were being documented and reviewed and there were systems in place to ensure that learning was being embedded.

  • The practice showed evidence to demonstrate they had been proactive in promoting cancer screening programmes and encouraging attendance.

  • The practice had reviewed access to appointments and increased the number of available clinicians, and additional clinics had been provided

  • For vulnerable patients, the practice had reviewed and negotiated improved access for patients who were homeless and staying at a local hostel. Double appointments were available for people with learning disabilities and reception staff were responsive to those with physical disabilities who accessed the practice for appointments.

  • The practice’s national GP survey remained low in some areas but the practice had commissioned its own survey and had analysed patient feedback in various other ways including “You said, we did” posters in the reception area.

  • Appropriate information was available to patients with regards to joint injections.

  • The practice worked to encourage attendance and improve uptake for national screening programmes that were below both local and national average at the last inspection by proactively sending personalised letters and calling patients, including those who consistently failed to attend. Cervical screening uptake had increased since our last inspection and was now in line with local and national averages.

However, there were also areas of practice where the provider should make improvements;

  • Review the complaints response letter and include details of who patients should contact if they are not satisfied.

  • Ensure that all Patient Specific Direction (PSD) forms are appropriate for their intended purpose.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Limes Medical Centre on 12 January 2017. Overall the practice is rated as requires improvement.

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

  • Systems and processes were in place to support the reporting and recording of significant events. Significant events were discussed with relevant staff but there was limited evidence that events were reviewed to ensure any learning was embedded.
  • Most risks to patients were assessed and well managed within the practice.
  • Staff used current evidence based guidance to plan and deliver care for patients. Staff had undertaken training to equip them with the skills and knowledge they required to deliver effective care.
  • Patient outcomes were generally in line with or above local and national averages. The practice was aware of areas for improvement and had been working to improve the uptake of the cervical cancer screening. However, uptake for other national cancer screening programmes was below average.
  • Feedback we received as part of the inspection indicated that patients felt they were treated with compassion, dignity and respect and found staff polite, friendly and helpful.
  • Information about services and how to complain was available and easy to understand. In addition information about raising complaints and concerns was provided in a number of different community languages.
  • Patients said they were generally able to make urgent appointments when these were required but a number of patients said it could be difficult to access routine appointments.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs.
  • There was a leadership structure in place and staff were positive about the support they received from management.
  • We saw evidence of action taken by the practice in response to feedback. For example in response to feedback from their patient participation group the practice had made improvements to their telephone system.

The areas where the provider should make improvement are:

  • Ensure all information related to significant events is documented and reviewed to check that learning identified has been embedded.
  • Continue to promote national cancer screening programmes and encourage attendance.
  • Continue to review and improve access to appointments; including ensuring ease of access for vulnerable patients.
  • Ensure feedback from patients is analysed and continue to take action to improve patient satisfaction levels
  • Review the information provided to patients in respect of joint injections.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 February 2014

During a routine inspection

On the day of our inspection we spoke with five patients, two doctors and three members of staff.

All patients we spoke with were satisfied with the appointment system and when necessary were given an appointment on the same day. Two patients told us they found it difficult to get through to the surgery by telephone at times. One told us: 'It can be a problem at busy times, but you have to keep trying.' One patient told us: 'If you avoid ringing them first thing in the morning, you can usually get through.'

We saw that patients' views and experiences were taken into account in the way the service was provided and that they were treated with dignity and respect. When patients received care or treatment they were asked for their consent and their wishes were listened to.

The practice is located in a modern single storey building. It is fully accessible for patients with disabilities. There were disabled parking bays close to the entrance in the car park. The surgery is also fitted with a hearing aid loop. One patient said: 'There's a nice atmosphere here. I've used this practice since it opened.'

We found the practice to be clean and well organised. Processes were in place to minimise the risk of infection. There were also processes in place for monitoring the quality of service provision. There was an established system for regularly obtaining opinions from patients about the standard of the service they received.