Alexandra Medical Centre

Updated 21 February 2024

Alexandra Medical Centre is located in Halesowen, West Midlands:

1 Short Street

Halesowen

West Midlands

B63 3UH

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

The practice is situated within the Black Country Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 3,170. This is part of a contract held with NHS England.

Information published by Public Health England shows that deprivation within the practice population group is ranked as level 4, with one being the most deprived and 10 being the least deprived. According to the latest available data, the ethnic make-up of the practice area is 86% White, 7% Asian and 7% Black, Mixed and other ethnicity.

The practice is run by two GP’s (male and female) and the clinical team includes a part time practice nurse and part time healthcare assistant. The clinicians are supported by a practice manager and 4 reception/administration staff. The practice had reduced management capacity for a period of six months due to unforeseen circumstance. This had impacted on some areas of leadership and governance oversight.

The practice is open between 8am to 6.30pm Tuesday, Wednesday, Thursday and Fridays and from 8am until 7.30pm on Mondays. Telephone consultations are available with a GP on Fridays between 7.30am and 8am and 6.30pm and 8.30pm. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. Evening appointments are available as part of the primary care network. Out of hours services are provided by NHS111.

The practice website can be viewed at: www.alexandramedicalcentrehalesowen.nhs.uk

Updated 21 February 2024

We carried out an announced focused inspection at Alexandra Medical Centre on 7 December 2023. Overall, the practice is rated as good.

Safe – good

Effective - good

Caring – rating of good carried forward from previous inspection.

Responsive - good

Well-led – good

Following our previous inspection on 6 August 2015 the practice was rated good overall.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

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:

• 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:

• Safeguarding systems were in place and staff demonstrated a clear understanding of the reporting and recording processes.
• We found the premises were well maintained, appeared visibly clean and tidy and there were appropriate infection prevention and control arrangements in place.
• There was a system in place to manage safety alerts, however this required strengthening to ensure historical alerts were revisited and accurately coded on the system.
• Structures, processes, and systems to support good governance were in place, however we identified gaps in mandatory training which required further oversight.
• Where we identified gaps in systems and processes, the practice responded in a timely manner to reduce risks to patients and staff.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• Patient feedback through the National Patient Survey was positive in relation to access and the provision of care.
• There was a strong emphasis of working with partners to tackle health inequalities.
• The practice provided a supportive culture with clear direction for the future of the service.

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

• Take action to increase the uptake of cervical screening.
• Take action to review and accurately code safety alerts.
• Improve the system in place to review patients with long term conditions who are due for monitoring checks.
• Take action to complete mandatory training requirements.
• Take action to ensure patient records are accurate, complete and contemporaneous.

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 Health Care