The Care Quality Commission
  • Doctor
  • GP practice

The Waterfront Surgery

Overall: Good read more about inspection ratings

Brierley Hill Health and Social Care Centre, Venture Way, Brierley Hill, West Midlands, DY5 1RU (01384) 481235

Provided and run by:
The Waterfront Surgery

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 Waterfront Surgery 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 Waterfront Surgery, you can give feedback on this service.

8 January 2020

During an annual regulatory review

We reviewed the information available to us about The Waterfront Surgery on 8 January 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

19 November 2018

During a routine inspection

This practice is rated as Good overall (Previous rating November 2017 – Requires Improvement). A breach of legal requirement was found and a requirement notice was served in relation to good governance. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for The Waterfront Surgery on our website at .

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Waterfront Surgery on 19 November 2018. This was to follow up on breaches of regulations and confirm the practice had met the legal requirement in relation to the breach in regulation that we had previously identified.

At this inspection we found:

  • The practice had made improvements since the previous CQC inspection and the breach in regulation had been addressed. However, we identified further improvement was required in some areas.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • The practice actively worked with the patient participation group (PPG) to meet the needs of their patients.
  • The management team had adopted a cohesive approach and had implemented a business plan to address future challenges.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review arrangements to manage uncollected prescriptions.
  • Further improve the management of patients on high risk medicines to follow best practice guidelines.
  • Implement an action plan to improve the uptake rates for cancer screening.
  • Formalise the clinical supervision provided to the nursing team.
  • Refresh staff training for the information governance arrangements regarding use of smartcards.
  • Continue to explore ways to improve patient satisfaction scores.

13 November 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. We previously carried out an announced comprehensive inspection in September 2016; the practice was rated as requires improvement, with the effective and caring key questions rated as requires improvement. The practice was rated as good for the safe, responsive and well-led key questions.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We carried out an announced comprehensive inspection at The Waterfront Surgery on 13 November 2017 to monitor that the necessary improvements since our last inspection had been made.

At this inspection we found that improvements had been made:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. They acted on their duty of candour appropriately.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. The practice had reviewed its recall system to ensure patients with long term conditions were offered timely reviews.
  • Staff treated patients with compassion, kindness, dignity and respect. Staff had completed customer service training to improve building rapport with patients.
  • Patients did not always find the appointment system easy to use and the practice had taken steps to improve monitor and remedy this. Patients mainly reported that they were able to access care when they needed it. The practice had a new telephone system with a queuing facility. They had reviewed peak times and adjusted staff rotas to increase staff operating telephones at these times. Comments we received on the day of inspection confirmed that the appointment system was better.

However, we found that in some areas, improvements were required.

Importantly, the practice must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. See the requirement notice at the end of this report for more details.

There were further areas identified where the provider should make improvements:

  • Ensure that complaints forms and leaflets are readily available.
  • Ensure all clinical staff have the opportunity to meet formally to share information concerns and improvements.
  • Further explore how to improve patient satisfaction scores particularly during consultations with a GP and for access to care and treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

6 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at The Waterfront Surgery on 6 September 2016. This was a follow up to an announced comprehensive inspection on 17 December 2015. During the inspection in 2015 we found the practice was in breach of legal requirements. The breaches related to:

Regulation 17 HSCA (Regulated Activities) Regulations 2014 Good Governance

Regulation 12 HSCA (Regulated Activities) Regulations 2010 Cleanliness and infection control

Following the inspection, the practice was placed into special measures, the practice wrote to us to say what they would do to meet the legal requirements. We undertook this inspection on 6 September 2016 to check that they had followed their plan and to confirm that they had met the legal requirements.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was an open and transparent approach to safety and an effective system had been put in place for reporting and recording significant events. Staff had regular monthly meetings to discuss significant events and lessons learnt. The practice carried out an analysis of each event with a documented action plan.
  • Systems and processes had been put in place to keep patients safe and risks to patients were assessed and well managed and the practice had good facilities and was well equipped to treat patients and meet their needs.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • An infection control audit had been completed and we saw evidence that identified actions had been addressed.
  • We saw that staff were friendly and helpful and treated patients with kindness and respect. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was a programme of continuous learning and meetings to support staff and involve them in the development of the practice.
  • From April 2016 Dudley Clinical Commissioning Group agreed with some practices to suspend the Quality & Outcome Framework (QOF) and have introduced a monitoring framework for long term conditions which the practice are actively using.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easier to make an appointment with the new telephone system in place and urgent appointments were available the same day.
  • The practice worked closely with other organisations in planning how services were provided to ensure that they meet patients’ needs. For example, the practice offered minor surgery services to the local population.
  • There was a clear leadership structure and staff felt supported by management.
  • business continuity plan had been put in place to guide staff on the procedures to follow if there was a major disruption to business.
  • The practice had a Patient Participation Group in place and was actively trying to encourage new patients to join.
  • The practice had introduced a programme of audits that were driving improvement in performance to improve patient outcomes.

However there were areas of practice where the provider should make improvements:

  • Continue to review the registers for patients with long term conditions and mental health needs to ensure appropriate reviews are in place.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Waterfront Surgery on 17 December 2015. Overall the practice is rated as inadequate.

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

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available and easy to understand.
  • There was a leadership structure and staff felt supported by management.
  • The practice had no business continuity plan in place to guide staff on the procedures to follow if there was a major disruption to business
  • Risks to patients was not always assessed and managed appropriately for example we saw evidence of patient’s care plans that had not been completed.
  • There was a system in place for reporting and recording significant events, however it was unclear of what action had taken place and the lessons learnt.
  • The practice did not have a Patient Participation Group in place and on speaking with patients there was no evidence that feedback had been sought from them in the past. Results from the national patient satisfaction survey had not been used to consider ways to further improve the practice.
  • Patients told us they struggled to get an appointment by telephone and this was reflected in the national survey and on NHS Choices feedback section.
  • Limited audits had been carried out, there no evidence that audits were driving improvement in performance to improve patient outcomes

There were areas of practice where the provider must make improvements.

The provider must:

  • Have a robust system in place to ensure safety alerts have been reviewed and actioned in order to assess the risks to patients receiving care.

  • Review the system for assessing and managing infection control within the practice, for example implement actions to address identified concerns following an infection control audit

  • Implement systems for seeking and acting on feedback received from patients in order to evaluate and improve services.

  • Consider future risks to the practice and patient and ensure that a business continuity plan is in place to mitigate risks where appropriate.

  • Review the management of test results to ensure results are acted upon appropriately and in a timely manner.

  • Review the schedule of both clinical and non-clinical audits in order to assess, monitor and improve the quality and safety of the service.

There were also areas of practice where the provider should make improvements

The provider should:

  • Review the process for managing medicines that are no longer in use and out of date.
  • Review how nursing staff are kept up to date in the absence of full clinical meetings.
  • Consider how they assure themselves that risks in relation to the environment have been assessed and appropriately managed.
  • Ensure that all staff have a cycle of appraisals, with the opportunity to discuss performance and training needs.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice