Oakeswell Health Centre

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 people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

We found the monitoring of most medicines was in line with clinical guidance to ensure all patients received the appropriate care and reviews.

Systems were in place to protect individuals from abuse and avoidable harm. We found safeguarding procedures were in place and safety was clearly prioritised across the service.

Health and safety procedures were regularly monitored, and the premises were appropriately maintained. Any actions identified were acted on to reduce potential risks.

We found safety incidents were investigated, and there were processes to share learning to identify shortfalls and prevent recurrence. Regular practice meetings were in place where learning was shared with the practice team to mitigate any future risks.

This service scored 79 (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 the majority of people’s care and treatment was effective by assessing and reviewing their 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 50 people. We reviewed a random sample of 5 clinical records and found 4 patients had not had a follow up review following an exacerbation and 2 patients had not received an annual asthma review. We discussed the findings with the clinical team who provided assurances that a review of the clinical search would be undertaken to ensure all patients were reviewed appropriately.Following the onsite assessment, we received evidence to demonstrate that immediate action had been taken following the clinical review. This included additional targeted asthma clinics to ensure patients who have not had a review within the last 12 months were seen promptly and a 48-hour post steroid follow up system to check patients after rescue steroids have been prescribed. The practice team told us they planned to audit the impact of these changes to ensure the quality of services provided was maintained and regularly monitored.

We carried out a clinical search on patients who had hypothyroidism and had not received the appropriate monitoring in the past 18 months. The search identified potentially 5 people. We reviewed each clinical record and found 4 patients had received the appropriate monitoring and the 1 outstanding patient had been invited for review.

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 your average level of blood glucose over time. We reviewed a random sample of 5 clinical records and found the appropriate reviews had been completed.

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. 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. 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.

The service always 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. They worked to develop evidence-based good practice and standards.

The clinical leadership team were consistently reviewing clinical guidelines to ensure patients were receiving high quality personalised care. We found the team had been proactive in reviewing the prescribing of gabapentoids, a group of medicines used to help with neuropathic pain. In July 2025, an audit had been completed to identify the number of patients currently being prescribed these types of medicines as there were potential risks to long term continued use. The audit identified 215 patients. A review of each patient was carried out which included risk factors and the benefits of the patient continuing on these medicines. Following the review the practice repeated the audit and found they had decreased the number of patients using gabapentoids by 69%, this represented a total of 149 patients. A re-audit had been completed in November 2025, to review the effectiveness of the interventions the clinical team had implemented. The audit showed significant improvements in prescribing and a successful reduction in high-risk medicine combinations.

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 worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

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.

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 always supported people to manage their health and wellbeing to fully 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.

Staff focussed 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.

The practice had made reasonable adjustments to provide support to vulnerable patients. This included home visits for patients who were unable to attend the practice.

The practice had been involved in a range of initiatives. This included:

• Being awarded Gold for the quality of the learning disability health checks they provided. The clinical team completed 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. 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 clinical team, before any decisions were made. This ensured a consistent approach for the patient and carers.
• The practice had hosted a carers event in June 2025. The event was held to provide information to carers on the support available locally. Community teams attended including Sandwell Young Carers. Staff provided support for the event including clinical pharmacists and administration staff. Following the event the leadership team planned for a meeting with Sandwell Young Carers, the GPs and clinical staff of the services available and the support that can be provided to young people with caring responsibilities.
• Some of the practice staff had taken part in the Race for Life to raise funds for cancer research. The practice team had raised over £4000 to support this charity event.

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 64.1% for people aged between 25 to 49 years of age and for people aged 50 to 64 years, had achieved 70.2%. To encourage people to attend their appointments, appointments were available at different times throughout the week to provide choice and a range of availability. The practice had achieved 4 out of the 5 national targets for childhood immunisations. Patients that failed to attend appointments were followed up and information was shared with the health visiting team.

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.