The Care Quality Commission
  • Doctor
  • GP practice

The Limes Medical Centre

Overall: Inadequate read more about inspection ratings

172 High Street, Lye, Stourbridge, West Midlands, DY9 8LL (01384) 426929

Provided and run by:
The Limes Medical Centre

Important:

We issued a notice of decision to The Limes Medical Centre on 24 June 2024 for failing to meet the regulations relating to safe care and treatment and good governance at The Limes Medical Centre.

All Inspections

During an assessment under our new approach

The Limes Medical Centre is a GP practice and provides a range of primary medical services. The GP practice is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the following regulated activities, diagnostic and screening procedures, family planning, midwifery and maternity services, surgical procedures and treatment of disease, disorder or injury. We inspected and rated this service under our previous methodology on 17 March 2022. The practice was rated requires improvement overall, and for key questions safe, and well-led, effective, caring and responsive was rated as requires improvement.

We carried out an announced assessment of 28 quality statements, under the safe, effective, responsive, and well-led key questions between 4 June and 19 June 2024. The assessment was carried out remotely and included an on-site assessment on 6 June 2024. A further unannounced assessment was carried out on 19 June 2024. The service has been rated as inadequate for key questions of safe and well-led and inadequate overall. Effective and responsive was rated as requires improvement.

As a result of our assessment findings, this service will be placed in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

17 March 2022

During an inspection looking at part of the service

We carried out an announced inspection at The Limes Medical Centre on 17 March 2022. Overall, the practice is rated as Requires Improvement.

The ratings for each key question are as follows:

Safe - Requires Improvement

Effective - Good

Well-led – Requires Improvement

Following our previous inspection on 15 November 2016, 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 The Limes Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection for Safe, Effective and Well-led due to concerns around the safety, governance and management of the practice.

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
  • 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 Requires Improvement overall

We found that:

  • There was a lack of oversight of safeguarding processes to keep people safe and safeguarded from abuse.
  • There were gaps in safeguarding training and not all staff were trained to the appropriate levels for their role.
  • There was an absence of appropriate staff recruitment checks to ensure safety.
  • Checks of staff immunisation status or appropriate risk assessments had not been completed for all staff.
  • The process for reporting and learning from significant events needed strengthening with all staff as the practice did not always share learning and improvements.
  • 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. Patients could access care and treatment in a timely way.
  • There was a lack of good governance in some areas and monitoring procedures were not always carried out consistently and effectively.
  • There were systems for managing risks, issues and performance, however this needed strengthening to ensure that the services were safe or that the quality was effectively managed.
  • There was limited evidence to demonstrate that the practice involved patients, staff or stakeholders in shaping the service.
  • The practice culture did not effectively support high quality sustainable care.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found breaches of regulations, the provider should:

  • Continue to embed processes for infection prevention and control.
  • Continue to strengthen processes for the recall and reviewing of patients with long term conditions.
  • Continue to increase the uptake for cervical screening.
  • Implement processes to engage with staff and patients so that learning can be shared, and quality of services provided can be improved further.
  • Continue with steps to engage with a patient participation group.

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

15 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of The Limes Medical Centre, in January 2016. As a result of our comprehensive inspection breaches of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified an area where the provider must make improvement and additional areas where the provider should improve.

We carried out a focussed desk based inspection of The Limes Medical Centre on 15 November 2016 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Limes Medical Centre on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:

  • Since our comprehensive inspection in January 2016, the practice had embedded an effective system to monitor and track the use of their prescriptions. We saw evidence to support this as part of our desk based review.
  • When we inspected the practice during January we found that learning and outcomes from incidents were not communicated widely enough and effectively in order to support improvements. As part of our desk based review we saw minutes of meetings which supported how learning was shared in the practice. Monthly practice meetings took place and key topics such as significant events and complaints were discussed during the meetings. We also saw records which demonstrated that staff received appraisals.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Limes Medical Centre on 13 January 2016. Overall the practice is rated as good.

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

  • There was a system in place for reporting and recording significant events. However, learning and outcomes from incidents were not communicated widely enough and effectively in order to support improvements.
  • The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There were procedures in place for monitoring and managing risks to patients’ and staff safety.
  • The practice did not have an adequate system in place to monitor the use of their prescriptions and for tracking their whereabouts.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Feedback during the inspection highlighted that staff would benefit from more frequent meetings to improve communication.
  • Information for patients about the services available was easy to understand and accessible. Information about how to complain was available and easy to understand and evidence showed the practice responded openly and quickly to issues raised.

The areas where the provider must make improvement are:

  • Ensure the use of prescriptions is adequately tracked and monitored.

The areas where the provider should make improvement are :

  • Ensure learning and outcomes from incidents are communicated widely enough and effectively in order to support improvements.
  • Ensure staff performance and training needs are identified and documented through a regular programme of annual appraisals.
  • Improve communication and ensure staff needs are listened to and used to drive improvements to the quality and safety of services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 May 2014

During an inspection looking at part of the service

We previously inspected The Limes Medical Centre on 14 October 2013. We found that improvements were required and asked the provider to submit an action plan outlining how they intended to address the issues we had identified.

At this inspection visit we looked to see what improvements had been made. We met three GP partners and spoke with two of the partners. We spoke with staff members including the practice manager, two reception staff and the advanced nurse practitioner. We also spoke with nine patients so that we could get their views with regards to the service provided.

At this inspection we were given mixed comments from patients about the way one GP communicated with patients. Some patients told us the GP did not explain things to them about their health needs. This was similar to our findings at the previous inspection; however we noted improvements had been made by the practice to ensure all patients felt involved in their care and were respected. This work was on-going at the time of our inspection.

At our last inspection we also found that there was an unacceptable gap in staff annual appraisals. This meant that they had not been adequately assessed as being competent. At this inspection we found that appraisals had been carried out and most staff we spoke with said that they felt supported in their role.

14 October 2013

During a routine inspection

During our inspection we spoke with seven patients and eight members of staff.

Patients told us they were treated with respect and that staff protected their right to privacy. We were given a mixture of positive and negative comments about the way that Doctor B communicated with patients.

We saw that patients' views and experiences were taken into account in the way the service was provided. The patients we spoke with provided positive feedback about their care. A patient told us: "It's very good. Whatever I say they are attentive. I really wouldn't go elsewhere". Patients received their medicines when they needed them and their medicines were regularly reviewed.

Staff had received training in safeguarding children and vulnerable adults. They were aware of the appropriate agencies to refer safeguarding concerns to that ensured patients were protected from harm.

We found that staff had received appropriate training for the roles they carried out. There was an unacceptable gap in staff annual appraisals. This meant that they had not been adequately assessed as being competent.

The provider had systems in place for monitoring the quality of service provision. There was an established system to regularly obtain opinions from patients about the standards of the services they received. However, where negative comments had been received they had not always taken action to ensure that on-going improvements were made for the benefit of the patients.

We discussed with the practice manager why there was a need for the provider (senior partner) to make an application to register for the regulated activity of maternity and midwifery services. We were informed by the practice manager that an application had been made and sent to the Care Quality Commission before the inspector had left the premises.