Walsall Wood Health Centre

We carried out an announced comprehensive inspection at Walsall Wood Health Centre on 2 September 2022. Overall, the practice is rated as Requires Improvement.

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led - Inadequate

Why we carried out this inspection

We carried out this inspection to as this was a new registration with the CQC.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• The practice was unable to demonstrate effective leadership. The lack of adequate processes were putting patients at risk and the provider did not have the capability to lead effectively and drive improvement.
• The governance processes were ineffective to manage risk. For example: we found some patient safety alerts had not been acted on and the process for recording and acting on significant events needed strengthening to ensure learning was shared to mitigate future risk.
• On reviewing the clinical records of patients we found no evidence to demonstrate that appropriate reviews had been completed before medicines were prescribed.
• There were limited emergency medicines available and no risk assessments had been completed in the absence of emergency medicines to determine the level of risk when responding to an emergency situation.
• Infection prevention and control audit had identified improvements that need to be acted on, however, the practice was unable to provide a plan to demonstrate these actions were being addressed.
• On reviewing a sample of staff files, we found limited records of the recommended immunisations required for staff and no risk assessments had been carried out to identify potential risks to patients and staff.
• Recruitment processes were ineffective, and the practice was unable to demonstrate that staff had the appropriate skills and knowledge to carry out their roles. We found limited evidence to show staff received regular reviews and appraisals.
• On reviewing the appointment system, we found the GP did not undertake afternoon clinics twice a week. This was not detailed on the practice website. We were unable to gain assurances that in his absence there was sufficient clinical cover to provide care to patients.

We found 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.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services