The Care Quality Commission
  • Doctor
  • GP practice

Birtley Medical Group

Overall: Good read more about inspection ratings

Durham Road, Birtley, Tyne and Wear, DH3 2QT (0191) 492 1022

Provided and run by:
Birtley Medical Group

All Inspections

5 December 2023

During an inspection looking at part of the service

We carried out a targeted assessment of Birtley Medical Group in relation to the responsive key question. This assessment was carried out on 5 December 2023 without a site visit. Overall, the practice is rated as Good. We rated the key question of responsive as Requires improvement.

Safe - Good

Effective – Good

Caring - Good

Responsive – Requires improvement

Well-led – Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for the

Birtley Medical Group on our website at www.cqc.org.uk

Why we carried out this review.

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the assessment

This assessment was carried remotely.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider

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:

  • During the assessment process, the provider highlighted the efforts they are making or are planning to make to improve the responsiveness of the service for their patient population.
  • The effect of these efforts are not yet reflected in patient feedback. Patient feedback was that they could not always access care and treatment in a timely way. Patients were dissatisfied with the arrangements for getting through to the practice by phone and their experience of obtaining an appointment.

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

  • Continue with their plan of responding to patient concerns/feedback about access and their experience of making an appointment with an aim to improve patient experience.

​​​​​​​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

20 May

During a routine inspection

We carried out an announced inspection at Birtley Medical Group on 20 May 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 14 March 2018, 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 Birtley Medical Group on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • Is the practice Safe?
  • Is the practice Effective?
  • Is the practice Caring?
  • Is the practice Responsive?
  • Is the practice Well-Led

How we carried out the inspection/review

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 inspections 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 and questionnaires.
  • 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 and Good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm though some areas required development.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. However not all patients were satisfied with the service they received.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue to develop and improve accessibility for patients.
  • Continue to develop and improve internal systems to ensure compliance with safety alerts over time.

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

14 March 2018

During a routine inspection

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

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

We carried out an announced comprehensive inspection at Birtley Medical Group on 14 March 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had systems in place to manage risk so that safety incidents were less likely to happen.
  • The practice could demonstrate effective clinical audit and quality improvement activity that led to improvements in patient care and outcomes
  • The practice 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 monitored and responded to the needs of their patient population. They had introduced extended opening hours to reflect the needs of patients who worked and reviewed the way in which they delivered care and treatment to their older and housebound patients.

There were areas where the provider should make improvements:

  • Consider offering all carer’s registered with the practice an annual health check
  • Review access arrangements for patients with mobility issues
  • Review the risk assessment supporting the decision not to hold a supply of recommended emergency medicines on the premises.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Birtley Medical Group on 13 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for the following population groups: Older people; People with long-term conditions; Families, children and young people; Working age people (including those recently retired and students); People whose circumstances may make them vulnerable; People experiencing poor mental health (including people with dementia).

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which they acted on.

However there was one area of practice where the provider needs to make improvements.

The provider should

  • Ensure that all clinical audits completed measure whether agreed standards are being achieved, and make recommendations and take action where standards are not being met. Three of the seven audits we reviewed included repeat audit cycles, where the practice was able to demonstrate the changes resulting since the initial audits had been carried out. Not all of the clinical audits completed measured whether agreed standards had been achieved or made recommendations and took action where standards were not being met.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice