Meadowbrook Surgery

Updated 24 October 2023

Meadowbrook Surgery is located in Halesowen:

4 Meadowbrook Road

Halesowen

West Midlands

B63 1AB

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Black Country Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 6,700. This is part of a contract held with NHS England.

The practice is not part of a Primary Care Network (PCN) but has access to services within the locality.

Information published by Public Health England shows that deprivation within the practice population group is ranked as level eight, with one being the most deprived and 10 being the least deprived. According to the latest available data, the ethnic make-up of the practice area is 93% White, 7% Black, Asian, Mixed and Other.

The practice is run by three GP partners (male) and the clinical team includes two part time nurses. The clinicians are supported by a practice manager and a team of reception/administration staff.

The practice is open between 8.30am to 6pm Monday, Tuesday, Wednesday, Friday and from 8.30am until 12pm on Thursdays. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. The practice commissions an out of hours provider when the practice is closed: Monday to Friday between 8am and 8.30am and 6pm and 6.30pm and Thursday’s 12pm-6.30pm. Out of hours services are provided by NHS111.

Updated 24 October 2023

We carried out an announced comprehensive inspection at Meadowbrook Surgery on 14 September 2023. Overall, the practice is rated as requires improvement.

Safe – requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

Following our previous inspection on 17 August 2015, the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Meadowbrook Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

This was a comprehensive inspection to review the following domains:

• Safe
• Effective
• Caring
• Responsive
• Well-led

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• Patients’ needs were assessed; however, care and treatment was not always delivered in line with current standards and evidence-based guidance. For example, we identified concerns in relation to medicines management, the diagnosis of conditions, and monitoring and follow-up of patients with long-term conditions.
• Medicines and Healthcare products Regulatory Agency alerts were not always promptly actioned.
• The practice learned from incidents, events and complaints and ensured learning was shared amongst the staff team.
• We found the premises were well maintained, appeared clean and tidy and had appropriate infection prevention and control arrangements in place.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• There were governance systems in place, however they did not always work effectively, in particular the oversight of medicines management and the coding of patients with diagnosis or long term conditions.

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 a breach of regulation, the provider should:

• Take steps to ensure all risk assessments are carried out for all staff where a disclosure and barring check has not been required.
• Take action to complete mandatory training for staff employed at the practice.
• Take action to ensure safeguarding registers are reviewed and accurate.
• Take action to complete sepsis training.
• Take action to record the day of the week for patients prescribed Methotrexate in line with best practice.
• Take action to review patients in a timely way where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is in place.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care