Great Barr Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At the last inspection we found the practice did not have a fully embedded governance system, there was a lack of leadership and oversight, the culture did not always effectively support high quality sustainable care and there was no evidence of systems and processes for learning, continuous improvement and innovation.

At this assessment, we found that systems still required strengthening to ensure the safety of patients and staff. The provider had not ensured that staff working in clinical areas had the necessary qualifications and skills to do their role effectively. A range of risk assessments had been completed, however we found action plans had not been acted on to ensure risks were mitigated.

The providers planned to increase the number of staff in the leadership team to provide ongoing support to staff and ensure there was adequate oversight and systems in place to manage risk, issues and performance. The practice had implemented designated roles for areas of accountability. On the day of assessment the practice told us they had a business continuity plan, however the management team were unable to locate it. We were unable to gain assurances that processes had been embedded and learning was shared with staff to sustain improvements.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last inspection we found that the practice culture did not always effectively support high quality sustainable care. However, during this inspection staff told us that there had been some improvements in the culture and communication and most staff now felt supported by the leadership team, however some staff still felt unable to raise concerns. Regular meetings were held with staff and the management team, however we found that complaints and learning from incidents was not shared to mitigate future risk and to promote learning. Staff told us that the leadership listened to what they had to say, but suggestions or actions were not acted on.

The practice website detailed the vision and values of the practice. This included to be at the forefront of modern general practice, offering a wide range of services and facilities, using technology to improve efficiency and effectiveness and to invest in staff developing skills and knowledge base. Staff we spoke with were unaware of the practice vision.

There were systems to ensure compliance with the requirements of the duty of candour and processes in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

The practice vision was not being followed by the leadership team. We found that staff had not been reviewed to ensure they had the appropriate skills to do their role and developmental opportunities that staff had highlighted as part of their personal development were not being actioned.

We received whistle blowing concerns which related to the effectiveness of patients' care and treatment, which had been investigated by the practice. Concerns were raised by the leadership team on the actions of some clinical staff which they had addressed, however there had been a delay in their actions and we found no evidence to demonstrate that concerns had been discussed with the appropriate staff to ensure future risks were mitigated and learning was shared.

We found leaders did not have the appropriate oversight and supervision to ensure staff were carrying out their roles effectively. We were unable to gain assurances that the leaders understood the challenges to quality and sustainability to ensure there was capable and effective leadership.

We were unable to gain assurances from the leadership team that they were aware of the skills and knowledge of staff they had employed. We found staff acting outside of their competencies without any clinical oversight. Changes to the nursing team were being implemented, however on speaking with staff we were unable to gain assurances that there was an effective system in place for clinical supervision.

Staff told us there had been improvements in the culture since the last inspection and most staff felt supported. There were regular meetings held with staff and there was a freedom to speak up guardian in place.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue.

As part of the practice’s mandatory training, we saw evidence that all staff had completed equality and diversity training.

We found plans were in place to recruit additional staff, with a clinical pharmacist having been employed to support the clinical team and a practice manager was due to start in January 2025 to support the existing leadership team. Staff told us they had completed equality and diversity training, and most said they were treated fairly and there was an open-door policy.

We found limited processes in place to review and improve the culture of the practice in relation to equality, diversity and inclusion. There were limited processes to support staff to feel empowered or confident that their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation.

There were policies and procedures in place for the safe recruitment of staff, however we found that staff had been employed for roles where they had not completed the appropriate qualifications. All staff had completed equality and diversity training and had access to regular appraisals, however some staff reported that personal development that had been identified had not been followed up and we were unable to gain assurances that there was clinical supervision in place.

Staff told us that practice policies were accessible, however on the day of the onsite assessment, we found that some policies could not be found. For example: Business Continuity Plan. On speaking with staff we found they were unaware of any business continuity plans.

We found there was no clear oversight for the management of risk. For example: we found actions identified through the health and safety and fire risk assessments had not been actioned. Further review found that the infection control audit that had been completed in April 2024 and had identified a number of actions to be compliant, had also not been acted on and the leadership team were unaware of what needed to be done to mitigate risk.

During the assessment in May 2024 we identified people who were high risk and required a clinical review. At this assessment we found that some of the people previously identified still had not been followed up as required. Further reviews of the clinical system showed some people with long term conditions had been seen by unqualified staff and we found no evidence to demonstrate that there was clinical supervision or oversight in place to ensure people were seen by staff who had the appropriate competencies.

We found processes required strengthening to ensure risk monitoring was effective. We were unable to gain assurances that actions from risk assessments had been completed for health and safety, fire and actions identified from the infection control audit. There was an ineffective process to identify, understand, monitor and address current and future risks including risks to people's safety. This included ensuring learning was shared to mitigate future risk and identify trends. We found that quality outcomes framework (QOF) performance was monitored but this was not always effective to ensure patients were receiving the appropriate care and in a timely way. On reviewing a random sample of people on high-risk medicines or with long term conditions we found they had not received the appropriate or timely reviews.

At the last assessment in May 2024, the practice had plans to organise a patient participation group. We found that this had now been implemented with a group newly formed.

We found practice meetings were now being held regularly and most staff reported that communication and the culture at the practice had improved. On speaking with the nursing team, they told us that they have no involvement with local nursing teams or meet with other nurses to share learning.

During the onsite assessment we spoke with two new members of the patient participation group which had recently been set up. We were told that there are currently 6 members and the group had met twice. The group and the practice leadership team are working on encouraging patients from a range of diverse and demographic backgrounds to join. In order to promote the group, the practice was looking at utilising social media.

We found no evidence to demonstrate that the practice was working with stakeholders to ensure that resources were planned and there was regular collaboration and partnership working to meet the needs of the patients.

We found some evidence to demonstrate that the practice had processes in place for partnership and community engagement. For example, we received evidence to demonstrate that safeguarding meetings were being held, however we were unable to gain assurances that these meetings and the outcomes were being shared with health visitors or local community services. No evidence was provided to demonstrate that regular meetings were held with other community teams to ensure patients receive the appropriate support, care and treatment.

We spoke with a range of staff on the day of the onsite assessment. Staff told us they had completed the relevant training to do their role and their competencies had been signed off by a member of staff who had the appropriate experience and qualifications to confirm that they were able to do their role effectively. However, we found that staff were carrying out clinical reviews of patients without having the qualifications, competencies or experience to do so and staff who had signed them off were also not qualified to make a decision about another staff member's competencies.

All newly appointed staff had completed a programme of induction and training which was reviewed by leaders to ensure training was monitored and kept up to date.

Feedback from staff highlighted they had identified areas of personal development, but this had not been actioned by the leadership team. Practice meetings were now in place, however we found there was no set agenda and learning from complaints and significant events were not shared with the practice team.