Poplars Medical Practice

Updated 23 December 2022

Poplars Medical Practice is located in Wolverhampton. The registered address for the practice is at:

122 Third Avenue

Low Hill

Wolverhampton

West Midlands

WV10 9PG

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.

The practice is situated within the Black Country Integrated Care Board (ICB) Integrated Care System (ICS) and provides services to patients under the terms of a general medical services (GMS) contract. This is a contract between general practices as independent contractors and NHS England to provide general medical services to its patient population of approximately 3,357.

The practice is part of a wider primary care network (PCN) of GP practices called Unity East Network. A PCN is a wider network of GP practices that work together to address local priorities in patient care.

Information published by Public Health England shows that deprivation within the practice population group is in the first decile (one 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 68.5% White, 12.7% Asian, 10.5% Black and 7.5% Mixed. The remaining 1.3% are categorised as other ethnicity. The age distribution of the practice population is mainly made up of working age. There is a similar number of male patients and female patients registered at the practice.

Currently due to the long-term absence of the registered provider the practice clinical team consists of one male GP who works full time 10 sessions per week, an advanced nurse practitioner and a practice nurse both of whom work part time. The practice also has the support of a clinical pharmacist through the primary care network. The clinical staff are supported by a practice manager, and administration, secretarial and reception staff. Staff are employed either full or part time hours to meet the needs of patients.

The practice is open between 8am and 6.30pm Monday to Friday. Patients are offered different types of appointments dependent on need and clinical triage assessments between the hours of 9am and 5pm. When the practice is closed extended hours access is provided locally through the PCN local hub arrangements, where late evening, weekend and public holiday appointments are available. Out of hours services are provided by NHS 111.

Updated 23 December 2022

We carried out an announced comprehensive at Poplars Medical Practice on 25 October 2022. Overall, the practice is rated as good.

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

Previous inspections carried out at Poplars Medical Practice included an announced comprehensive inspection on 28 December 2014 as part of our inspection programme. The practice was rated inadequate for providing safe, effective and well led services, requires improvement for providing responsive services and good for the provision of caring services. The practice was rated inadequate overall and placed in special measures.

We carried out an announced focused inspection out on 18 November 2015 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations we identified at our previous inspection on 28 December 2014. At the focused inspection on 18 November 2015 we found that the practice had resolved the concerns raised and met the requirement notices issued. However, a new issue was identified and the practice was rated requires improvement for providing safe services with an overall rating of good.

A focused inspection carried out on 28 January 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breach in regulations we identified at our previous inspection on 18 November 2015. At the inspection we found that the practice had met the requirement notice and was rated as good for providing safe services.

An inspection was undertaken on the 16 March 2021. This was a focused inspection, carried out in response to concerns received by the Care Quality Commission (CQC). The inspection was not rated however, requirement notices were issued relating to safe care and treatment and Good Governance. At this inspection, 25 October 2022 we found that all the requirement notices had been met.

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

Why we carried out this inspection:

We carried out this inspection to follow up breaches of regulation from a previous inspection carried out in March 2021.

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 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 provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
• Staff files were not all organised so that relevant documents were readily and easily accessible in one place.
• We found that the immunisation status of all staff was not consistently available to demonstrate any immunisation that was incomplete.
• The practice had a system for recording and disseminating actions carried out as a result of significant events to support learning and improvement.
• The practice had taken appropriate action to support and protect patients identified as at risk from harm.
• Patients received effective care and treatment that met their needs.
• Although patients medical reviews were mostly comprehensively and clearly documented to provide details of the review and its outcome we noted that there were some gaps.
• There was a below average uptake by patients of preventative treatments in particular, cervical screening and some age groups for childhood immunisations
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The results of the National GP Patients survey identified that patients had a positive experience of the practice and felt there was access to timely care and treatment.
• The practice leaders had management oversight of staff qualifications and training.
• Staff were clear and knowledgeable about their roles and responsibilities.
• Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
• The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centred care.

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

• Continue to improve the organisation and accessibility of staff recruitment records.
• Provide evidence that staff vaccination and immunity for potential health care acquired infections are recorded or risk assessed for all staff.
• Provide evidence that staff who are qualified to administer medicines under the authorisation of patient group directions have signed current and updated authorisations before administering the medicines.
• Review the risk assessments in place for emergency medicines not routinely held at the practice so that they contain sufficient information to demonstrate how the level of any risk will be mitigated.
• Implement systems for the ongoing monitoring and review of the completeness of documentation and updating of patient records following clinical and medicines reviews.
• Introduce processes for the ongoing review and follow up of safety alerts to demonstrate that any changes or action taken in response to the alert is maintained.
• Improve the uptake of childhood immunisations and cervical cancer screening.
• Continue to proactively identify carers so that they can be supported to access services available to them.

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