Glebefields Surgery in Tipton is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, maternity and midwifery services, services for everyone and treatment of disease, disorder or injury. The last inspection date here was 21st November 2017
Glebefields Surgery is managed by Dr Raymond Sullivan.
Contact Details:
Address:
Glebefields Surgery St Marks Road Tipton DY4 0SN United Kingdom
Telephone:
01215308040
Ratings:
For a guide to the ratings, click here.
Safe: Good
Effective: Good
Caring: Good
Responsive: Good
Well-Led: Good
Overall: Good
Further Details:
Important Dates:
Last Inspection
2017-11-21
Last Published
2017-11-21
Local Authority:
Sandwell
Link to this page:
Inspection Reports:
Click the title bar on any of the report introductions below to read the full entry. If there is a PDF icon, click it to download the full report.
Letter from the Chief Inspector of General Practice
We first inspected Dr Raymond Sullivan’s surgery on 16 November 2016 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Ray Sullivan’s surgery on our website at www.cqc.org.uk. During the inspection, we found the practice was in breach of legal requirements this was because appropriate processes were not in place to mitigate risks in relation to the safety and quality of the services offered. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.
This inspection was an announced focussed inspection, carried out on 13 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall we found improvements had been made to the concerns raised at the previous inspection and as a result of our inspection findings the practice is now rated as Good.
Our key findings across all the areas we inspected were as follows:
Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Since the previous inspection, an effective system had been implemented to ensure all incidents were acted on and learning was shared with all staff members. The practice carried out an analysis of each event with a documented action plan.
We found that the practice had reviewed their processes for receiving safety alerts and all alerts were actioned upon receipt and actions taken were recorded and discussed as part of the clinical team meetings, which were held every week.
At this inspection, we saw a programme of clinical audits had been implemented to monitor patients’ outcomes and improve the quality of care provided.
We saw evidence to confirm that staff had received the appropriate checks with the disclosure and barring service (DBS).
At our previous inspection we found the practice did not have effective systems and processes to monitor patients on high risk medicines. This risk had been mitigated with the implementation of guidelines to monitor patients on high risk medicines, the support of a clinical pharmacist and a review of all patients to ensure they were receiving the appropriate care.
The practice had a number of governance policies and procedures in place, which had been reviewed and updated. The governance arrangements to assess and monitor the
quality of services showed improved outcome with a schedule of regular governance meetings in place since the last inspection in November 2016. This included monthly team meetings and weekly clinical meetings.
At this inspection we saw evidence that an IT training needs analysis had been completed and identified gaps in staff’s IT knowledge had been actioned.
The practice proactively sought feedback from staff and patients, however at our previous inspection, we were told there was a patient participation group (PPG) but they did not meet regularly and were not actively involved in practice developments. At this inspection, the practice told us they had tried to encourage patients to join the group and had sought support from the clinical commissioning group (CCG). A virtual group had been planned and the practice were still looking at this possibility. A PPG meeting had been arranged for the end of October 2017 which was on display in the waiting room to advise patients.
The practice had achieved in cervical screening with 91% of patients having had a cervical screening test in the past five years, the practice had been asked to participate in a cervical screening workshop for primary care providers by Public Health England to share good practice and educate primary care about strategies to increase cervical screening coverage.
Following our previous inspection, the practice had recruited a clinical pharmacist to support the GPs in monitoring prescribing and effective auditing of medicines.
Letter from the Chief Inspector of General Practice
We first inspected Dr Raymond Sullivan’s surgery on 16 November 2016 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Ray Sullivan’s surgery on our website at www.cqc.org.uk. During the inspection, we found the practice was in breach of legal requirements this was because appropriate processes were not in place to mitigate risks in relation to the safety and quality of the services offered. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.
This inspection was an announced focussed inspection, carried out on 13 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall we found improvements had been made to the concerns raised at the previous inspection and as a result of our inspection findings the practice is now rated as Good.
Our key findings across all the areas we inspected were as follows:
Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Since the previous inspection, an effective system had been implemented to ensure all incidents were acted on and learning was shared with all staff members. The practice carried out an analysis of each event with a documented action plan.
We found that the practice had reviewed their processes for receiving safety alerts and all alerts were actioned upon receipt and actions taken were recorded and discussed as part of the clinical team meetings, which were held every week.
At this inspection, we saw a programme of clinical audits had been implemented to monitor patients’ outcomes and improve the quality of care provided.
We saw evidence to confirm that staff had received the appropriate checks with the disclosure and barring service (DBS).
At our previous inspection we found the practice did not have effective systems and processes to monitor patients on high risk medicines. This risk had been mitigated with the implementation of guidelines to monitor patients on high risk medicines, the support of a clinical pharmacist and a review of all patients to ensure they were receiving the appropriate care.
The practice had a number of governance policies and procedures in place, which had been reviewed and updated. The governance arrangements to assess and monitor the
quality of services showed improved outcome with a schedule of regular governance meetings in place since the last inspection in November 2016. This included monthly team meetings and weekly clinical meetings.
At this inspection we saw evidence that an IT training needs analysis had been completed and identified gaps in staff’s IT knowledge had been actioned.
The practice proactively sought feedback from staff and patients, however at our previous inspection, we were told there was a patient participation group (PPG) but they did not meet regularly and were not actively involved in practice developments. At this inspection, the practice told us they had tried to encourage patients to join the group and had sought support from the clinical commissioning group (CCG). A virtual group had been planned and the practice were still looking at this possibility. A PPG meeting had been arranged for the end of October 2017 which was on display in the waiting room to advise patients.
The practice had achieved in cervical screening with 91% of patients having had a cervical screening test in the past five years, the practice had been asked to participate in a cervical screening workshop for primary care providers by Public Health England to share good practice and educate primary care about strategies to increase cervical screening coverage.
Following our previous inspection, the practice had recruited a clinical pharmacist to support the GPs in monitoring prescribing and effective auditing of medicines.
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