Black Country Family Practice

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• 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.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has been changed to Good.

We found some patients with long term conditions had not been monitored appropriately. Patients received care and treatment that supported them to live healthier lives including being supported to undertake national screening programmes and vaccinations. Patients who required monitoring underwent regular checks on their health.

Multi-disciplinary meetings were held where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for.

This service scored 71 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified 59 people. We reviewed a random sample of 5 clinical records and found recommended guidelines for the follow up of a patient following an exacerbation had not been followed. We discussed the clinical findings with the practice team and were assured that there was a process in place now to review patients within 48 hours of an exacerbation in line with clinical guidelines.

Further reviews of the clinical system identified people with diabetes who had a HbA1c of 75 and over. A haemoglobin A1C (HbA1C) test is a blood test that shows average level of blood glucose over time. We reviewed a random sample of 5 clinical records and found 3 patients had not received the appropriate reviews in the past 12 months.

Feedback from people using the service was positive. 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. 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.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We spoke with staff who were able to describe the process for coding of correspondence and care and treatment records for people.

Staff we spoke to were aware of the workflow and clinical staff were able to demonstrate how the practice provided further education and support to patients. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

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.

Clinical searches showed the appropriate reviews and monitoring had been completed for a range of long term conditions. For example: We reviewed a random sample of 5 records of patients with chronic kidney disease stage 4 and 5 and found all the appropriate monitoring had been completed.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

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 told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral.

The practice learning disability lead was proactive in working together with the community learning disability team and liaised with them regularly to discuss new patients to the surgery or patients that required extra support, for example when attending hospital appointments. Further evidence provided showed how practice learning disability lead had developed clear, written guidance for colleagues within the practice to provide step-by-step instructions along with the rationale for each stage of the health check process to ensure high quality standards were maintained.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was co-ordinated effectively.

The primary care network (PCN) helped to support the practice by providing links to pharmacists, physiotherapists and social prescribers. People were able to receive co-ordinated care between the practice and the PCN.

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.

The practice had recently been awarded Gold for the quality of the learning disability health checks they provided. One of the advanced nurse practitioners (ANP) had taken the lead on all components of the health checks including physical examinations and health condition reviews and had used a range of various reasonable adjustments and creative engagement techniques to ensure patients’ needs were comprehensively assessed. When patients were unable to attend the practice, home visits were arranged, this also included health screening where appropriate. We were shown examples of how the comprehensive processes had supported patients with learning disabilities receive advanced health checks to ensure their needs were being met. Safeguarding alerts were on clinical records and on speaking to a range of staff we found that all staff were aware that any concerns relating to a patient with learning disabilities were to be discussed with the ANP, before any clinical decisions were made. This ensured a consistent approach for the patient and carers.

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

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The practice was below the national target of 80% uptake for cervical screening with the practice having achieved 67.6% for people aged between 25 to 49 years of age and for people aged 50 to 64 years, had achieved 68.5%. To encourage people to attend their appointments, clinics were organised at different times throughout the week to provide choice and a range of availability. The practice was below all 5 national targets for childhood immunisations. Following a review of all practices within the Modality Birmingham group, a standard operating procedure had been introduced in June 2025 to improve uptake. This included standardising processes for identifying new babies and managing recalls and reducing missed appointments through a structured contact and escalation pathway. The leadership team were monitoring the uptake of appointments and found a reduction in the number of appointments being missed with follow up by clinicians for those patients who required further support and information.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people 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.