The Care Quality Commission
  • Doctor
  • GP practice

Pinfold Medical Also known as Pinfold Medical Services

Overall: Good read more about inspection ratings

Field Road, Bloxwich, Walsall, West Midlands, WS3 3JP (01922) 775134

Provided and run by:
Pinfold Medical

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Pinfold Medical on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Pinfold Medical, you can give feedback on this service.

20 and 29 September 2021

During an inspection looking at part of the service

We carried out an announced inspection at Pinfold Medical on 20 and 29 September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring – Good

Responsive - Good

Well-led - Good

Following our previous inspection on 3 and 6 March 2020, the practice was rated Requires Improvement overall. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pinfold Medical on our website at www.cqc.org.uk

Why we carried out this inspection/review

This was a focused inspection to follow up on:

  • The safe, effective and well-led key questions
  • Any breaches of regulations or ‘shoulds’ identified at our last inspection.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive.

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 the practice as Good overall with the exception of People experiencing poor mental health (including people with dementia) which we rated as Requires Improvement.

We found that:

  • There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Patients received effective care and treatment that met their needs.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment. There was clinical oversight and effective systems for quality improvement.
  • Although the practice remained below the threshold for long term condition reviews and cervical screening rates, they were able to evidence that an action plan was underway to improve outcomes with progress monitoring in place.
  • Mental health indicators were below local and national averages which had declined further since our last inspection and action taken had not yet demonstrated improved outcomes.
  • 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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Although our clinical searches identified some issues with high risk medicine management, these issues were not systemic, and the provider demonstrated they had the capacity and capability to address them.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. There were systems and processes in place for the recruitment of staff in accordance with the regulations.
  • We found health and safety, fire safety risk assessment, security risk and infection control assessments had been completed at the practice premises.

Whilst we found no breaches of regulations, the provider should:

  • Continue to strengthen processes for the reviewing high risk medicine and actioning of safety alerts.
  • Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
  • Continue with steps to review those patients with long term conditions.
  • Continue to increase the uptake for cervical, breast and bowel screening.
  • 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

03/03/2019 and 06/03/2019

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection at Pinfold Medical (previously known as All Saints Surgery) in January 2019 as part of our inspection programme. The practice was rated requires improvement. The report on the January 2019 inspection can be found by selecting the ‘all reports’ link for Pinfold Medical on our website at www.cqc.org.uk.

We carried out an announced focused inspection at Pinfold Medical on 3 and 6 March 2020. At this inspection we followed up on breaches of regulations identified at the previous comprehensive inspection in January 2019.

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.
  • information from the provider, patients and other organisations.

We rated this practice as requires improvement overall and in well-led and effective, we rated safe as good. We rated each population group as good except for people with long-term conditions and working age people, which we rated as requires improvement in the effective domain. This was because the quality indicators were below average and target for cervical cancer screening had not been met. Because of the assurance received from our review of information we carried forward the ratings for providing caring and responsive services.

We rated the practice as good in providing safe services because:

  • The practice had taken appropriate action to meet the requirements of the regulation 17 breach.
  • The practice had made improvements in many areas and had sought additional managerial support on a consultancy basis.
  • We found that the practice had an up to date log and identified actual events and near misses which they recorded as learning events. There was documented evidence that events were discussed and learning shared. The investigative process did not identify all contributory causes, but the practice had already identified this for themselves and were in the process of deciding which root cause analysis would work for them.
  • Staff employed in advanced roles had their clinical decisions reviewed formally and were supported with informal supervision when required.
  • The practice had a comprehensive alert system which recorded the alert, who was contacted, action taken, and the practice had plans to ensure it showed when ongoing or repeated audit would be required.
  • Emergency medicines were either stocked as required or had a comprehensive risk assessment in place to explain why they were not in stock.

We rated the practice as requires improvement in providing effective services because:

  • The quality indicators were below average people with long term conditions had not received an annual review.
  • Cervical cancer screening rates were significantly below the national target.

We rated the practice as requires improvement in providing well-led services because:

  • the practice had not developed an effective quality improvement programme.

The areas where the provider must make improvements are:

  • 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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Take formal action to ensure that the practice looks like one practice.
  • Improve the signage to promote ease of access for patients.
  • Continue to develop their significant event process with a clear root cause analysis process.
  • Take action to categorise significant events as events not near misses.
  • Formalise records of clinical audit and quality improvement activity.
  • Review and improve the call and recall policy for people with long term conditions.

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

During a routine inspection

We carried out an announced comprehensive inspection at All Saints Surgery on 22 January 2019 as part of our inspection programme. The practice was last inspected in September 2015 and rated as good.

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 rated the practice as requires improvement for providing safe services because:

  • The practice did not have a system in place that demonstrated that alerts with may affect patient safety had been received, recorded and acted upon.
  • The practice could not demonstrate that patients’ health in relation to the use of medicines including high risk medicines was appropriately monitored or that clinical review took place prior to prescribing.

We rated the practice as requires improvement for providing well led services because:

  • There had been a lack of strategic oversight and planning to bring about the creation of the new organisation. While the practice had a clear vision, that vision was not supported by a credible strategy.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.
  • The provider had not updated their registration to reflect the changes to the partnership and regulated activities following the merger in April 2018.

We rated the practice as good for providing effective, caring and responsive services because:

  • 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards.
  • Update the registration of the provider to reflect the change in partnership and the registered manager and the registration of additional regulated activities.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review the register of children with child protection plans in place as well as looked after children to ensure the information is up to date and current.
  • Create and maintain a register of vulnerable adults as appropriate for patients aged over the age of 18 years.
  • Record all verbal complaints so they can be reviewed for trends and identify any lessons to be learnt.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

25 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at All Saints Surgery on 25 September 2015. Overall the practice is rated as good.

Specifically, we rated the practice as good for providing safe, effective, caring, responsive and well led services. The service provided to the following population groups was rated as good:

• Older people.

• People with long-term conditions.

• Families, children and young people.

• Working age people (including those recently retired and students).

• People whose circumstances may make them vulnerable.

• People experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected 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.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • There was a clear leadership structure and staff felt supported by management.

However, there were areas of practice where the provider needs to make improvements.

The provider should :

  • Undertake risk assessments when appointing staff with a Disclosure and Barring Service (DBS) check from a previous employer and develop systems to record necessary recruitment checks completed for all staff including locums.
  • Review the results of the 2015 national GP patient survey and consider whether improvements are needed to improve patients’ experience of the service.
  • Develop systems to monitor and record staff training so that training needs can be easily identified and acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice