Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Bourbrook Varsity Medical Centre on 7 December 2017. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our inspection programme.

At this inspection we found:

• The facilities and premises were appropriate for the services delivered and we observed them to be visibly clean and tidy.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.
• The practice organised and delivered services to meet patients’ needs. For example, the practice actively offered in house counselling, depression screening and further support to students who were experiencing poor mental health.
• There was evidence of adequate systems in place to support good governance. There were positive relationships between staff and teams and the practice had a culture of high-quality sustainable care.
• There were high levels of patient satisfaction at the practice.
• Patients told us they were satisfied with the service and we noted that the Care Quality Commission comment cards we received were extremely positive about the service experienced, many of the cards highlighted that the staff frequently went above and beyond for their patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bournbrook Varsity Medical Centre on 6 July 2016. Overall the practice is rated as good.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed. The practice carried out an annual significant event audit to ensure learning from significant events was embedded.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. The GPs were leads in different areas and had fortnightly meetings to discuss concerns and share learning.

• There was a clear leadership structure and staff felt supported by the GPs and the practice manager. The practice proactively sought feedback from staff and patients which it acted on. There was a very proactive Patient Participation Group (PPG) of which we met with four members during the inspection.

• The practice was aware of and complied with the requirements of the duty of candour.

• Risks to patients were assessed and well managed.

• Patients described staff as caring and helpful. Patients commented that they were treated with dignity and respect

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

• As the practice was very busy in September and October with new student registrations from the university the practice used their conference rooms for a few weeks over this period to help students with registrations.The practice gave close attention to assisting overseas students. Members of staff were also there to educate students about the NHS and choosing appropriate services.

We saw an area of outstanding practice:

• Each year the practice had an annual flu day which the Patient Participation Group supported. The number of patients who attended the 2015 flu day was 336 patients. Prior to this the practice ensured that housebound patients and care home residents received their flu vaccine.Outside agencies also attended the local flu day to educate patients for example health trainers and the local safety officers. All patients would also have their blood pressure, height and weight measured.

However, there were areas of practice where the provider should make improvements:

The provider should:

• Review how care and treatment is planned for patients with a learning disability.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice