Background to this inspection
Updated
9 June 2021
Quincy Rise Surgery is located at:
30 Sandringham Way,
Quincy Rise,
Brierley Hill,
West Midlands,
DY5 3JR
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 and West Birmingham Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS). This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices in the Brierley Hill Primary Care Network (PCN).
Information published by Public Health England report deprivation within the practice population group as eight on a scale of 1 to 10. Level one represents the highest levels of deprivation and level 10 the lowest.
The National General Practice Profile states that 95% of the practice population is from a white ethnic background with a further 5% of the population originating from black, Asian, mixed or other non-white ethnic groups.
The practice is led by a single-handed GP who employs a salaried GP, a locum practice nurse, a locum advanced nurse practitioner and a healthcare assistant (HCA). The clinical team are supported by a practice manager and five part time receptionists.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Extended access is provided locally by Brierley Hill Primary Care Network (PCN), where late evening and weekend appointments are available. Out of hours services are provided by West Midlands Ambulance Service via NHS 111.
Updated
9 June 2021
We carried out an unannounced focused inspection at Quincy Rise Surgery on 21 October 2020 and found breaches against Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was an unrated inspection however, warning notices were issued against Regulation 12(1) Safe care and treatment, Regulation 17(1) Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Following our inspection in October 2020, the practice wrote to us with an action plan, outlining how they would make the necessary improvements to comply with the regulations. The provider submitted additional information and evidence to us electronically to demonstrate improvements had been made to comply with the regulations.
We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of follow-up inspection was necessary and proportionate. As a result, we carried out a remote assurance review of this information, which included a virtual meeting with the provider, on 2 February 2021 to confirm whether the practice had taken sufficient action to comply with the warning notices. We found the provider had made improvements and was compliant with the Warning Notices issued. The practice was not rated as a result of this review.
We carried out an announced inspection at Quincy Rise Surgery on 10 and 11 May 2021 to assure us that the practice was compliant with the regulations. Overall, the practice is rated as Good overall.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Quincy Rise Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This was a comprehensive inspection to follow up concerns from our inspection on 21 October 2020 which led to breaches against Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
How we carried out the inspection
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 inspection 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
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 all population groups with the exception of people experiencing poor mental health (including those with dementia) which we rated as requires improvement.
We found that:
- Systems and processes to keep patients safe had been improved. The practice had acted to address areas of identified non-compliance.
- Staff had completed the required training for their roles. Systems were in place to manage and monitor training for staff in the practice.
- Disclosure and Barring Service (DBS) checks had been completed for all staff and recruitment checks were in accordance with the regulations.
- There was a lead for infection prevention and control. A recent audit had been completed and all staff had completed training.
- Processes to assess, monitor and manage governance and safety systems had been improved.
- The practice had undertaken a review of medicines held for dealing with medical emergencies. Risk assessments had been completed for those medicines not held on-site.
- The practice had developed systems to manage and monitor emergency equipment held within the practice and had carried out regular checks of that equipment.
- There was a formalised approach to staff meetings for practice improvements.
- Staffing had been strengthened for clinical and non-clinical staff with oversight and review as part of the leadership management.
- Clear processes had been established and set out as part of managing risk, issues and performance.
We have rated the population group of people experiencing poor mental health (including those with dementia) as Requires Improvement because:
- Mental health indicators were below local and national averages and action taken had not yet demonstrated improved outcomes.
Whilst we found no breaches of regulations, the provider should:
- Continue to review immunisation needs against possible infections for staff in non-clinical patient facing roles.
- Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
- Continue work to identify and support carers registered at the practice.
- Continue with steps to engage with a patient participation group.
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