The Care Quality Commission
  • Doctor
  • GP practice

Bucklands End Lane Surgery

Overall: Requires improvement read more about inspection ratings

36 Bucklands End Lane, Castle Bromwich, Birmingham, West Midlands, B34 6BP 0845 675 0588

Provided and run by:
Bucklands End Lane Surgery

All Inspections

19 September 2023

During a routine inspection

We carried out an announced comprehensive at Bucklands End Lane Surgery on 19 September 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement,

Effective - good,

Caring – requires improvement,

Responsive - requires improvement,

Well-led – good.

During the inspection process, the practice highlighted efforts they were making to improve telephone and appointment access for their patient population. These had only recently been implemented so there was not yet verified evidence to show they were working and had improved patient satisfaction.

The provider also told us of their plans to expand the premises, however these plans were awaiting planning permission and had not been confirmed.

As such, the ratings for this inspection have not been impacted by these improvement initiatives. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.

Following our previous inspections, the practice was rated good overall and for all key questions.

At this inspection, we found some areas that required improvement in the safe, caring and responsive key questions. The practice is therefore now rated requires improvement overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bucklands End Lane 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.

We inspected the following key questions:

• 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 shorter 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:

  • Most safety and governance systems the provider had implemented, kept patients safe and protected them from avoidable harm.
  • Some systems such as the management of infection prevention and control, security of blank prescriptions and calibration of medical equipment required improvement.
  • Patients received effective care and treatment that met their needs.
  • Patients on high risk medicines or those patients with long term conditions were monitored and followed up in line with guidelines.
  • The provider was aware that uptake with children’s immunisations was below target and they were taking appropriate action to improve this.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patient feedback indicated that patients could not always access care and treatment in a timely way. However, the provider was taking appropriate action to improve access.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The provider was aware of the challenges it faced and told us of the action they had taken to improve. The provider responded to any concerns that were raised during the inspection and took immediate action to improve the safety of services.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

The provider should:

  • Continue to take action to improve telephone and appointment access.
  • Improve processes to be able to demonstrate that the impact of actions taken to improve patient satisfaction are being monitored and further action is taken when actions have not had the desired outcome.
  • Improve governance of health and safety processes to include monitoring and mitigation for all possible risks and hazards relating to staff and premises.
  • Take action to improve uptake of cervical cancer screening.
  • Take action to improve processes to ensure all carers including young carers are identified.
  • Continue to take action to improve uptake with childrens’ immunisations.

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

3 September 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection of Buckland’s End Lane Surgery on 3 September 2019. We carried out an inspection of this service 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 significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: Well-led and Effective (including effective care across the six population groups). The six population groups are:

  • Older people
  • People with long-term conditions
  • Families, children and young people
  • Working age people (including those recently retired and students)
  • People whose circumstances may make them vulnerable
  • People experiencing poor mental health (including people with dementia)

Because of the assurance received from our review of information we carried forward the Good ratings for the following key questions: Safe, Caring and Responsive (including responsive services for the six population groups).

You can read the reports from our last inspections by selecting the ‘all reports’ link for Buckland’s End Lane Surgery on our website at www.cqc.org.uk.

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.

Following this inspection we have rated this practice Good for providing well-led services and Good for providing effective care to all the population groups.

We found that:

  • There were clear and effective processes for managing risks and the practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • Patients’ needs were assessed and care and treatment was delivered in line with current legislation and evidence-based guidance. There was also evidence to support that regular multidisciplinary working took place with inclusion from other health and social care services.
  • We saw evidence of effective quality improvement activities undertaken in the practice to improve care and services for patients.
  • The practice had a clear vision and credible strategy to provide high quality sustainable care.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management in most areas.
  • There was evidence of positive performance across many clinical areas including some areas of cancer reviews and childhood immunisations uptake and we noted efforts to improve in areas where practice achievement was below average or under target.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue with efforts to improve uptake of childhood immunisations in specific areas and cancer screening.
  • Improve the governance of the safety alert system utilised in practice.
  • Continue with efforts to address IT issues inherited on the patient record system, in order to avoid exception reporting as a work-around.

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

20 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bucklands End Lane Surgery on 20 July 2015. Overall the practice is rated as good.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • 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.
  • 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 easy to understand.
  • Patients had mixed views about the appointment system; some said that they had difficulty making an appointment by telephone and others said that they were always able to get an urgent appointment the same day.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there was an area of practice where the provider needs to make improvements.

Importantly the provider should:

  • Ensure a robust system is in place to monitor the safe use of prescriptions in the practice.
  • Document checks of the battery operated equipment used in the premises.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice