Background to this inspection
Updated
9 July 2021
Swanpool Medical Centre is located at Tipton, an area in the West Midlands. The practice has good transport links and there is a pharmacy located nearby.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, surgical procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury. These are delivered from both sites.
Swanpool Medical Centre is situated within the Sandwell and West Birmingham Clinical Commissioning Group (CCG) and provides services to 9,185 patients under the terms of a General Medical Services contract (GMS). This is a contract between general practices and NHS England for delivering services to the local community. The principal GP, Dr Devanna Manivasagam is registered with CQC as a GP partnership. Dr Devanna Manivasagam is also the principal GP of three other GP practices. These include: Clifton Medical Centre, Bean Road Medical Centre and Stone Cross Medical Centre.
Practice staffing consists of three GP partners (one male and two female) and one full time salaried GP. The practice employs a practice nurse, a clinical pharmacist and several administration staff. The practice is part of a wider network of GP practices. The leadership team consists of the provider, executive manager and assistant practice manager.
The practice opening times are 8am to 6.30pm, Monday to Friday. There was also extended access appointments available in the evening and weekends from 6.30pm to 8pm Monday to Friday and 9am to 12pm on Saturday and Sunday. Due to the COVID-19 pandemic extended access appointments had been temporarily suspended. The extended access service was provided as part of a joint working arrangement with other local practices within the Primary Care Network (PCN). Extended access appointments were booked by patients through their GP practice and patients were seen in various practices across the PCN.
The practice has opted out of providing an out-of-hours service. Patients can access the out of hours service provider by contacting the NHS 111 service.
The National General Practice Profile states that 88.4% of the practice population are from a white ethnicity. Information published by Public Health England, rates the level of deprivation within the practice population group as one, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
Updated
9 July 2021
We carried out an announced inspection at Swanpool Medical Centre between 14 to 21 May 2021. Overall, the practice is rated as Requires Improvement.
The ratings for each key question were as follows:
Safe - Requires Improvement
Effective – Requires Improvement
Caring – Requires Improvement
Responsive - Good
Well-led – Requires Improvement
Following our previous inspection on 8 January 2020, the practice was rated Inadequate overall and for all key questions, except for providing caring and responsive services which were rated as requires improvement. The practice was placed into special measures. A GP Focused Inspection Pilot (GPFIP) between 14 September 2020 and the 2 October 2020 was also carried out to check what improvements had been made.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Swanpool Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection to follow up on any breaches of regulations and ‘shoulds’ identified in the previous inspection.
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:
- 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 shortened 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 Requires Improvement overall and requires improvement for all population groups, except for families, children and young people, older people and people whose circumstances make them vulnerable which we have rated as good.
We found that:
- The management of administration tasks needed improving. On reviewing the clinical system we found large numbers of tasks awaiting action and no management oversight was evident to ensure tasks were prioritised and acted on.
- Some improvements had been made in the management and monitoring of patients’ clinical conditions. However, the practice had seen a significant decrease in the percentage of people with mental health and dementia with agreed care plans in the previous 12 months. Following the inspection, the practice provided unverified data for 2020/2021 which showed improvements in agreed care plans for people experiencing poor mental health and people with dementia.
- On reviewing a random sample of patients records who had been prescribed an inhaler, we found formal reviews had not been completed and patients had been prescribed inhalers without the appropriate code on their records to identify them as having a condition that required this medicine.
- Since the previous inspection the leadership team had reviewed the practice procedures and implemented effective processes to ensure staff training was monitored and staff completed training relevant to their role.
- Processes had been implemented to ensure safeguarding registers were monitored and contained all the relevant information. Regular reviews of the registers were carried out and multi disciplinary meetings had been implemented to ensure information was shared effectively to protect patients from avoidable harm.
- Risk management processes had improved and risk assessments had been completed to ensure the safety of staff and patients and to mitigate any future risks.
- We found significant improvements in the management of patients’ care and treatment. on high risk medicines.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. This included individual risk assessments for staff, the use of personal protective equipment (PPE) and enhanced infection control procedures.
- Governance arrangements had been strengthened to ensure risks to patients were considered, managed and mitigated appropriately.
- The practice had implemented a system of peer review for the clinical team. On reviewing a sample of patient records we found prescribing decisions were in line with recognised guidance and consultations contained relevant information.
The areas where the provider must make improvements as they are in breach of regulations are:
• Regulation 17 HSCA (RA) Regulations 2014 Good governance
The areas where the provider should make improvements are:
- Develop processes to encourage patients to attend cervical screening appointments.
- Implement processes to encourage patients to attend childhood immunisation appointments.
- Improve processes to ensure patients who had been prescribed inhalers have been coded and reviewed appropriately.
- Implement stronger systems to ensure DNACPR information is recorded appropriately.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care