Halcyon Medical Centre

Updated 19 August 2022

Halcyon Medical Limited is located in the City Centre of Birmingham. The practice has a General Medical Services contract (GMS) with NHS England.

The provider is registered with the CQC to carry out the following regulated activities - diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures, family planning, maternity and midwifery services.

The practice provides NHS services to 11,806 patients. The practice is part of Birmingham and Solihull Integrated Care Board.

The practice is a limited company owned by the medical director who is also the registered manager. The medical director is supported by six salaried GPs (three female and three male), two GP registrars (one male and one female) and one FY2 (foundation year two placement) trainee doctor on their second year after graduation, two practice nurses and two health care assistants.

The non-clinical team consists of administrative and reception staff, a practice/business manager and an assistant practice manager.

The practice is an approved training practice and provides training to GP Registrars as part of their ongoing training and education.

The practice is currently part of a wider network of GP practices.

The practice opening times are 8am to 6.30pm, Monday to Friday and Saturday morning from 9am to 12pm.

The practice has opted out of providing an out-of-hours service. Patients can access the out of hours service provider by contacting the NHS 111 service.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth decile (four of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 45% White, 34% Asian, 12% Black, 5% Mixed, and 4% Other. The age distribution of the practice population is much lower than local and national averages for patients aged 65 years and over.

Updated 19 August 2022

We carried out an announced inspection at Halcyon Medical Limited on 4 and 6 July 2022. Overall, the practice is rated as Requires improvement.

Safe - Requires improvement.

Effective - Requires improvement.

Well-led - Requires improvement.

Following our previous inspection on 22 November 2021, the practice was rated Inadequate overall and for the safe and well-led key questions, Requires improvement for providing effective services and Good for providing caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Halcyon Medical Limited on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focussed inspection, carried out within six months of the service being placed into special measures to see if the provider had made the necessary improvements to provide safe and effective care.

• We inspected safe, effective and well-led key questions.
• We followed up on ‘shoulds’ identified in previous inspections.
• Ratings for caring and responsive are carried forward from the previous inspection in November 2021.

How we carried out the inspection

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.

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:

• Following our previous inspection in November 2021, the provider had improved safeguarding processes to keep patients safe and protected them from avoidable harm.
• The provider had improved processes to assess, mitigate and manage risk related to the premises.
• The provider had improved recruitment processes and continued to work with an external company to manage HR and staff performance issues.
• The practice had reviewed processes to effectively manage staff training information. We found that all staff had completed mandatory training relevant to their role.
• The provider had reviewed and improved infection prevention and control processes.
• We found patients did not always receive effective care and treatment that met their needs. The practice had not met four out of five minimum uptake targets for children’s immunisations and was achieving significantly below the national minimum target for cervical cancer screening.
• The practice had identified 12 new carers since the previous inspection. However, due to the high turnover of patients, their overall number of carers remained low at 36 patients. This was 0.3% of their patient list.
• The provider had responded appropriately to our warning notice and taken appropriate action to improve quality and safety. We found there had been improvements to governance processes, however, there was a divided culture amongst staff, some staff feeling they were not well supported or that the culture did not promote the delivery of high-quality, person-centred 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.

The provider should:

• Improve arrangements to manage work when staff were absent. This includes re-distribution of clinical and non-clinical workload.
• Improve access to vaccinations such as shingles and pneumococcal and NHS health checks.
• Implement systems to vaccinate patients with an underlying medical condition according to the recommended schedule and systems to identify people who misused substances.
• Improve the uptake of childhood vaccinations and cancer screening.
• Improve the clinical audit program to demonstrate improvements in quality of care and treatment delivered.
• Continue to recruit further staff, to allow existing staff time for non-clinical duties such as administration and training.
• Take action to ensure staff are aware their concerns are listened to and considered.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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