The Care Quality Commission
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  • GP practice

Archived: Church Road Surgery

Overall: Good read more about inspection ratings

28 Church Road, Aston, Birmingham, West Midlands, B6 5UP (0121) 411 0344

Provided and run by:
Church Road Surgery

Important: The provider of this service changed. See new profile

All Inspections

30 October 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Church Road Surgery on 30 October 2019, 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 change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

•Effective

•Well-led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

•Safe

•Caring

•Responsive

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.

We rated the practice as requires improvement for population group Families, children and young people because:

•The uptake of childhood immunisation was below the national target.

We rated the practice as good for providing effective and well led services because:

•The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.

Whilst we found no breaches of regulations, the provider should:

•Continue to promote and explore ways to improve the uptake of cancer screening and childhood immunisation.

•Review the systems to manage risk to ensure potential risks are assessed and managed effectively and regularly reviewed. For example, systems for monitoring staff training and consent, access to polices in the event of IT failure and the arrangements for the checking of equipment.

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

6 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This was a follow up desk-based review carried out on 6 February 2017, to confirm the practice had met the areas for improvement that we identified on our previous inspection on 29 September 2016. The full comprehensive report following the inspection on 29 September 2016 can be found by selecting the ‘all reports’ link for Church Road Surgery on our website at www.cqc.org.uk.

This report covers our findings in relation to those improvements.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • The practice had undertaken disclosure and barring service (DBS) checks for non-clinical staff members who chaperoned. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff had completed relevant training for chaperoning so that they were aware of their responsibilities when undertaking this role.

  • Health and safety and fire safety risk assessments had been completed and. staff had also received training in these areas.

  • Details of the practice opening times and various clinic times in the practice leaflet were not aligned on the practice website. For example, the opening hours for Monday and Friday afternoons and the finishing time for the well baby/Immunisation clinic were inconsistent. The practice manager told us that the information on the practice leaflet was incorrect and provided us with an updated practice leaflet which had information consistent with the website.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Road Surgery on 29 September 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Most risks to patients were assessed and well managed. The practice had not carried out fire and health and safety risk assessments. However, following the inspection the practice was able to demonstrate that they had been carried out.
  • Administration staff who carried out the role of a chaperone had not undergone a DBS assessment and a risk assessment was not in place. Following the inspection the practice had submitted evidence to confirm DBS checks on all staff were now being undertaken.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had a healthcare assistant (HCA) who was a qualified holistic therapist. Patients with mental health needs, those that had suffered bereavement and carers were referred to the HCA for holistic therapy such as relaxation, Reiki and reflexology.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The provider was aware of and complied with the requirements of the duty of candour.

  • There was a focus on continuous improvement. One of the GP partner had taken part in a minor surgery pilot and another GP partner was involved in regional development of stroke prevention.

The areas where the provider should make improvement are:

  • Ensure all staff have the necessary knowledge and understanding to adequately fulfil the role of a chaperone.
  • Ensure practice website and the information leaflet details in regards to opening and clinic times are aligned.
  • Review the systems and process in place to manage risk in the practice, for example in relation to chaperoning, health and safety and fire safety.

Professor Steve Field  CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

30 June 2014

During an inspection in response to concerns

We undertook this inspection after receiving concerning information about the practice. These concerns related to the care of patients requiring follow up or a review of their health condition at the practice. During our inspection we did not find any evidence to substantiate these concerns.

Our visit was unannounced so the practice was unable to prepare for it. We took a GP specialist advisor with us to assist with our inspection. During our visit we spoke with six members of clinical and administrative staff. This included the two GP partners, the practice manager, the practice nurse and two reception staff. We also reviewed documentation and records that were made available to us.

We found that patients at the practice experienced care, treatment and support that met their needs. The practice appropriately acted and responded to information received about patients from hospital consultants and medical tests. Patients with long term health conditions had their condition reviewed.

The practice had appropriate arrangements to help protect patients from the risk of abuse. Staff at all levels had an understanding of safeguarding issues and what to do if they had any concerns. We saw evidence that the practice responded appropriately to safeguarding concerns.