Background to this inspection
Updated
13 May 2019
Cotmore Surgery is located at 169 Old Oscott Lane, Great Barr, Birmingham, B44 8TU. The surgery has good transport links and there is a pharmacy located nearby.
Dr Paul Dudley and Dr Steven Gibbins are the registered providers of Cotmore Surgery. The provider is registered with CQC to deliver the following regulated activities:
- Diagnostic and screening procedures
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
Cottmore Surgery is situated within Birmingham and Solihull Clinical Commissioning Group (CCG) and provides services to 2,800 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and CCG for delivering services to the local community.
When the practice is closed, out of hours cover for emergencies is provided by Birmingham and District General Practitioner Emergency Room group (Badger). On call GPs are available on Wednesday afternoon from 1pm when the practice is only open for pre-booked appointments, complex care, minor surgery and emergencies.
The practice has two male GP partners, and two salaried GPs (one female and one male). The clinical team also includes three practice nurses. The non-clinical team consists of a practice manager and a team of secretaries, receptionists and administrators.
Cotmore Surgery is in a deprived area of Birmingham. The practice scored four on the deprivation measurement scale; the deprivation scale goes from one to 10, with one being the most deprived. People living in more deprived areas tend to have greater need for health services. National General Practice Profile describes the practice ethnicity as being 82% white British, 8% Asian, 6% black, 3% mixed and 1% other non-white ethnicities.
The practice demographics show a higher than average percentage of people in the 65+ year age group and a below average percentage of people aged under 18 years old. Average life expectancy is 80 years for men and 84 years for women compared to the national average of 79 and 83 years respectively. The general practice profile shows that 56% of patients registered at the practice have a long-standing health condition, compared to 50% locally and 51% nationally.
Updated
13 May 2019
We carried out an announced comprehensive inspection at Cotmore Surgery on 4 March 2019 as part of our inspection programme.
At the last inspection in October 2015 we rated the practice as good for providing safe, effective, caring, responsive and well-led services.
At this inspection, we found that the providers had satisfactorily moved in line with changes within the healthcare economy and had shaped the practice to sustain delivery of high-quality services.
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.
We rated the practice as good for providing safe, effective, caring, responsive and well-led services because:
- 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 scored above local and national averages in the 2018 national GP patient survey for questions relating to the care and treatment provided.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The way the practice was led and managed mostly promoted the delivery of high-quality, person-centre care.
We rated the practice as requires improvement for providing safe services because:
- Staff we spoke with demonstrated how to recognise and respond to safety concerns; however, records we viewed showed not all clinical staff had completed the required training. Following our inspection, the practice provided evidence of an action plan which showed staff were required to complete fire safety training by July 2019.
- The practice did not have a schedule in place for reviewing risk assessments for the management of Disclosure and Barring Service (DBS) checks and chaperoning.
- Risk assessments did not adequately mitigate risks associated with not stocking some suggested emergency medicines. Following our inspection, the practice reviewed arrangements and updated their risk assessment.
The provider should:
- Review systems and processes to ensure effective oversight of training needs and ensure that training provided satisfies published guidance and competency framework.
- Consider the need for a formal, regular review of risk assessments relating to Disclosure and Barring Service checks and associated risk assessments to ensure risks are considered and mitigated.
- Continue carrying out actions to improve the uptake of national screening programmes such as cervical screening.
- Continue reviewing arrangements and updating risk assessments to determine the range of emergency medicines held at the practice.
- Ensure a formal approach to managing significant events is established and embedded.
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