Background to this inspection
Updated
5 October 2021
Brown Clee Medical Centre is registered with the Care Quality Commission (CQC) as a partnership GP provider operating a GP practice in Shropshire. The practice is part of the NHS Shropshire Clinical Commissioning Group (CCG) and holds a General Medical Services (GMS) contract with NHS England. A GMS contract is a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract.
The practice operates from Brown Clee Medical Centre, Station Road, Ditton Priors, Bridgnorth Shropshire, WV16 6SS. The practice has a branch surgery at Stottesdon, High Street, Stottesdon, DY14 8TZ. Regulated activities are provided from these locations only. The practice area is one of lower overall deprivation when compared with the national averages. At the time of the inspection the practice had 3,758 registered patients. Overall the practice population is in line with local averages. The patient population is mainly White British (99%).
The staff team currently comprises a male and female GP partnership and a male salaried GP. The practice team includes two part-time practice nurses, a practice manager, accounts manager, three cleaners, a practice dispenser, two dispensers, two receptionist/dispensers, one reception clerk and an administrator for document scanning. In total there are 19 staff employed either full or part time hours.
At the Ditton Priors location, the practice opening times are 7.15am to 6pm Monday, Tuesday, Wednesday and from 8am and 6pm Thursday and Friday. At the Stottesdon location, the opening times are 9am to 12.30pm Monday, Wednesday, Thursday, Friday and from 9am and 12.30pm and 1.30pm and 4pm on a Tuesday. The practice does not provide an out-of-hours service to its own patients but has alternative arrangements for patients to be seen when the practice is closed through the out-of-hours service provider. The practice telephones switch to the out of hours service at 6pm each weekday evening and at weekends and bank holidays. The practice operates a dispensary from the Ditton Priors location and can dispense to patients who live more than one mile (1.6km) from the nearest pharmacy.
Further details about the practice can be found by accessing the practice’s website at www.browncleesurgery.com
Updated
5 October 2021
We carried out an announced focused inspection at Brown Clee Medical Centre on 16 August 2021. The practice is rated Good.
The ratings for each key question are as follows:
Safe - Good
Effective – Good
Caring - Outstanding
Responsive - Outstanding
Well-led – Requires Improvement
We carried over the ratings from the last inspection for the caring and responsive key questions.
Following our previous inspection on 30 July 2019, the practice was rated Requires Improvement overall and for key questions safe and well-led. The practice was rated Good for providing effective services and outstanding for providing caring and responsive services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Brown Clee Medical Centre on our website at www.cqc.org.uk.
Why we carried out this inspection.
This inspection was a focused inspection to follow up on a breach of Regulation 12 Health and Social Care Act 2208 (Regulated Activities) Regulations 2014, Safe care and treatment.
This was because:
- Not all staff had received up-to-date essential training.
- The safeguarding policy was not local to the practice and did not reflect current guidance.
- There was no documented risk assessment for the security of medicines held in the dispensaries.
- A system to track prescription stationery and security of prescriptions throughout the main location had not been implemented.
- A controlled drugs cabinet or register was not available at the branch location for the storage of these medicines whilst awaiting collection.
- The controlled drug cabinet at the main location did not meet the required standard.
- A risk assessment had not been undertaken in relation to key holding responsibilities for dispensing staff.
- The controlled drug standing operating procedures (SOP) did not provide dispensing staff with clear guidance on the management and dispensing of these medicines.
At the inspection in August 2021 we found that the provider had satisfied the requirements of the regulation.
How we carried out the inspection/review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
- A telephone call with a representative of the Patient Participation Group
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 have rated this practice as good overall and good for providing safe and effective services and requires improvement for providing well-led services. We rated all population groups as good.
We found that:
- Safety systems and processes to keep people safe and safeguarded from abuse had improved.
- The management and dispensing of medicines had been reviewed and improved.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- Staff understood their role and responsibilities in providing positive health outcomes for patients.
- Structures, processes systems to support good governance and management had improved overall but were not always effective.
- The practice continued to have very high patient satisfaction levels. The Practice achieved significantly higher results across all areas within the GP patient survey, compared to local and national averages. For example, 99% of respondents responded positively to their overall experience of this GP practice. A 100% of respondents responded positively to how easy it was to get through to the Practice on the phone.
The areas where the provider should make improvements are:
- Review and strengthen governance arrangements.
- Ensure the required staff recruitment checks are completed.
- Develop a system to ensure the immunisation status and registration of clinical staff are checked and regularly monitored.
- Ensure staff induction is documented.
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 General Practice