Central Clinic

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. We found that patients mostly received appropriate monitoring at the required intervals. There were a few areas for improvement we identified and raised with the provider so they could take this forward

Our remote clinical search identified the practice had 198 patients with asthma. We reviewed the clinical records for 4 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We found patients had received the appropriate treatments and monitoring, however, 2 of the 4 patients required a steroid card and 1 patient required further monitoring.

Our remote clinical search identified the practice had 84 patients with hypothyroidism. We sampled 3 of these patient records and found 1 patient required further monitoring.

Our remote clinical search identified the practice had 337 patients with diabetes. We sampled the records of 4 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We found these patients were generally monitored and reviewed, however 1 patient required further monitoring.

Our clinical searches identified 12 patients with chronic kidney disease stages 4 or 5. We found these patients had the required blood monitoring to assess their kidney function in the previous 9 months.

Systems were in place to manage and respond to safety alerts. However, our clinical searches identified the recommended monitoring was not always at the frequency required for frail people or those aged over 75 years. We discussed the frequency of monitoring with this specific cohort with the provider who agreed to take action.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support. For example,In April 2025, the practice hosted a PCN Dietitian led Healthy Eating Group Session and were the third highest referrer in the PCN to dietician services. Patients were able to access services such as diabetes prevention, smoking cessation, and obesity management through the Your Health Dudley.

There were flags on patients records who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

Staff focused on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Staff actively signposted patients to local support services offering information, education, and tailored advice based on individual needs. Patients were encouraged to participate in national health initiatives, such as cancer screening programmes and childhood immunisations.

The latest GP Patient Survey carried out, showed that 88% of respondents felt their needs had been met during their last general practice appointment which was in line with the local average and slightly below the national average of 90%.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Cervical screening uptake at the practice was 63% among patients aged 24–49 and 50–64, falling below the national target of 80%. Breast and bowel screening rates were also lower than national averages. Furthermore, national data indicated that all five indicators for childhood immunisations were below the World Health Organisation’s minimum threshold of 90%, with coverage ranging between 75% and 88%. The practice attributed this to challenges within the patient population, including high levels of deprivation and health behaviours that impact engagement with preventative care. Unverified data suggested that improvements were underway for cervical screening.

In collaboration with the PCN, the practice was actively working to reduce barriers linked to deprivation. This included supporting location planning for mobile breast screening units, deploying social prescribers to engage hard-to-reach patients, and delivering health promotion initiatives such as dietitian led group sessions.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency.

The service told patients about their rights around consent and respected these when delivering person centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.