Background to this inspection
Updated
2 December 2022
Clifton Medical Centre is located in West Bromwich at:
Clifton Lane
West Bromwich
West Midlands
B71 3AS
The practice has a branch surgery at:
Victoria Health Centre
Suffrage Street
Smethwick
West Midlands
B66 3 PZ
Both the main and branch surgery sites were visited as part of this inspection activity.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.
The practice is situated within the Black Country and West Birmingham Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 5,300. This is part of a contract held with NHS England.
The practice is part of the Health Vision Partnership Primary Care Network (PCN). A PCN is a wider network of GP practices that work together to address local priorities in patient care.
Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 58.4% White, 26.4% Asian, 8.9% Black, 6.3% Mixed and Other minority ethnic.
The age distribution of the practice population is slightly younger than the local and national averages. There is a similar distribution of male and female patients registered at the practice.
The practice is a family run partnership consisting of three GPs (one male and two female). There is one salaried GP and three long term locum GPs, a long-term locum Advanced Nurse Practitioner and two practice nurses. The clinical team is supported by a practice manager and a team of six administrative / reception staff.
The GP partners also run three other practices under separate provider registrations: Stone Cross Medical Centre, Swanpool Medical Centre and Bean Road Medical Centre. There is a Practice/Executive Manager that provides oversight of all the practices under the partnership including Clifton Medical Centre.
The practice is open between 8 am to 6.30 pm Monday to Friday. The practice initially offers a telephone consultation and if required a face to face appointment is made.
Extended access appointments are available weekdays 6.30pm to 8.30pm and weekends 9am to 1pm at Stone Cross Medical Centre. When the practice is closed, patients are directed to the Out of hours services through the NHS 111 service.
Updated
2 December 2022
We carried out an announced comprehensive inspection at Clifton Medical Centre between the 27 September 2022 and 12 October 2022. Overall, the practice is rated as requires improvement.
The ratings for each key question are as follows:
Safe - requires improvement
Effective - good
Caring - requires improvement
Responsive - requires improvement
Well-led - good
Following our previous inspection in May 2021, the practice was rated requires improvement for the effective and caring key questions and therefore rated requires improvement overall. The practice was rated good for the safe, responsive and well-led key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Clifton Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this comprehensive inspection to follow up on issues raised at our May 2021 inspection, in line with our inspection priorities.
The focus of inspection included:
- All key questions
- Any breaches of regulations or ‘shoulds’ identified in the previous inspection
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:
- Since our previous inspection the practice had continued to embed effective systems to keep patients safe and protected them from avoidable harm. This included the management of safeguarding concerns, recruitment process, safety alerts and patients on high-risk medicines. However, we also identified some areas where continued improvements were needed.
- We found the premises were well maintained and infection prevention and control (IPC) measures were in place.
- Our clinical searches found appropriate management of patients’ medicines. However, we found vaccines that were out of date. An investigation following the inspection identified no harm as a result.
- Incidents and complaints were used to support learning and improvement.
- Patients received effective care and treatment that met their needs. Our clinical searches found patients received appropriate follow up for their long-term conditions and improvements in outcome data.
- The practice was able to demonstrate quality improvement activity was undertaken.
- There was a high uptake of the practice’s mandatory staff training and the practice was able to demonstrate how it assured itself of the competence of staff in advanced roles.
- Patient feedback on the service was mixed. Results from the latest GP national patient survey in relation to questions about patient experience and access were below local and national averages. There was limited evidence to show what action was being taken to address this.
- The practice demonstrated that changes in the leadership and governance had led to improvements to support the delivery of high-quality person-centred care.
We found a breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
Whilst we found no breaches of regulations, the provider should:
- Include all household members in safeguarding alerts, such as parents, guardians and partners.
- Address any issues identified during our clinical searches of medicines and long-term conditions that require follow up. Including recording day of week when prescribing a specific Disease-modifying anti-rheumatic drug (DMARD), issuing steroid cards where appropriate and ensuring all DNACPR decisions are fully recorded.
- Conduct appropriate risk assessments for all staff whose immunisation status is not in line with recommended government guidance and take appropriate action where needed.
- Continue to improve the uptake of child immunisations and cancer screening.
- Update whistleblowing policy to ensure it is conducive with supporting staff to raise concerns.
- Improve action plan to address decline in patient satisfaction of the service.
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 Hospitals and Interim Chief Inspector of Primary Medical Services