26 October 2023
During a routine inspection
We carried out an announced comprehensive inspection at Yardley Green Medical Centre on 26 October 2023. Overall, the practice is rated as requires improvement.
Safe - good
Effective – requires improvement
Caring – requires improvement
Responsive - requires improvement
Well-led - good
Following our previous inspection in July 2017, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Yardley Green Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities. The focus of inspection included a review of all key questions.
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 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:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. This included safeguarding systems, safe recruitment, infection prevention and control and the management of the premises and associated risks.
- Our review of clinical records found safe management of medicines, in particular those that required ongoing monitoring due to adverse risks. However, processes for undertaking medicines reviews and alerts required improvement.
- Systems were in place to support the practice to learn and make improvements when incidents and complaints occurred.
- Patients received effective care and treatment that met their needs. Our review of clinical records found appropriate follow up of patients with or at risk of long-term conditions with the exception of asthma where improvements were needed to follow up patients requiring high doses of steroids.
- Uptake of childhood immunisations and cancer screening programmes was below national targets and national averages.
- Patient feedback from various sources was mixed about the way staff treated and involved them. Results from the GP national patient survey on questions relating to patient experience were lower than local and national averages.
- The practice was taking significant action to try and improve access to services, which included a new telephone system, increased staffing and expansion of the premises. Early data available was showing signs of improvement, helping patients to access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. There was a strong emphasis of working with partners to tackle health inequalities.
- The practice provided a supportive culture with clear direction for the future of the service.
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:
- Update policies accordingly, to ensure information contained within them is current and correct.
- Take action to improve uptake of cervical screening and other other cancer screening programmes.
- Take action to improve patient experience and patient involvement in the service to drive improvement.
- Continue to monitor access to ensure improvements are being delivered and take further action as needed.
- Improve systems and processes for the management of medicine and safety alerts.
- Take action to improve the identification of carers so that they may receive appropriate support.
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 Health Care