The Care Quality Commission
  • Doctor
  • GP practice

High Street Surgery

Overall: Good read more about inspection ratings

High Street, Cheslyn Hay, Walsall, West Midlands, WS6 7AB (01922) 701280

Provided and run by:
High Street Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about High Street Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about High Street Surgery, you can give feedback on this service.

18 January 2020

During an annual regulatory review

We reviewed the information available to us about High Street Surgery on 18 January 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

5 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously undertook a comprehensive inspection of High Street Surgery on 26 January 2016. The overall rating for the practice was Good with the Safe domain being rated as Requires Improvement. We found two breaches of legal requirements and as a result we issued requirement notices in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Safe Care and Treatment.
  • Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Fit and Proper Persons Employed

The full comprehensive report on the January 2016 inspection can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.

High Street Surgery and Landywood Lane Surgery merged on 1 July 2017. We previously undertook a comprehensive inspection of Landywood Lane Surgery on 22 September 2016. The practice was rated as Inadequate overall and placed into special measures. We found three breaches of a legal requirements and as a result we issued requirement notices in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Safe Care and Treatment.
  • Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Good Governance
  • Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Fit and Proper Persons Employed

The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Landywood Lane Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 5 October 2017. Overall the combined practice is now rated as good.

Our key findings were as follows:

  • The management team had undertaken a review of both services following the merger. This included working practices, policies and procedures and the overall governance framework. The management team recognised and identified the challenges and had developed an action plan to address these.
  • The practice had an overarching governance framework which supported the delivery of the strategy and good quality care. The management recognised that the framework needed to implemented and become embedded across both sites. Staff at the branch site were being supported through the implementation and cross site working was also being introduced.
  • There was a clear leadership structure and staff felt supported by management. The leadership and management provided to staff who previously worked at Landywood Lane Surgery had been strengthened following the merger.
  • Staff from the merged practice spoke positively about the changes that had taken place since the merger. They told us they felt supported by the management team from High Street Surgery, and efforts had been made to bring both teams together as one new team.
  • Improvements had been made to how the practice provided safe services. There was an open and transparent approach to safety and a system in place for reporting and recording significant events. The same policy and procedure had been adopted across both sites. Recruitment procedures had been strengthened and appropriate recruitment checks were undertaken. All staff had received Disclosure and Barring Service (DBS) checks.
  • Staff were aware of current evidence based guidance. NICE guidance was a standing agenda item at monthly clinical meetings which all clinical staff were expected to attend. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. There were plans to review the results for both practices to identify any areas were improvements could be made.
  • Improvements had been made to the availability of information for patients on how to complain at the branch site. Information about how to complain was available and evidence from examples reviewed showed the practice responded quickly to issues raised
  • Patients we spoke with said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • Patient feedback on comment cards was generally positive about the merger and the increased availability of appointments. Comments included being able to see a GP on a Friday afternoon, and being able to book a diabetic review any day rather than just one.
  • The provider was aware of the requirements of the duty of candour. The example we reviewed showed the practice complied with these requirements.

There were also areas of practice where the provider should make improvements.

The provider should:

  • Continue to review and update the policies and procedures and share these with staff.
  • Continue to monitor and encourage the uptake of the
  • Ensure that all uncollected prescriptions are reviewed by the GPs before being destroyed.
  • Provide additional fire marshals at the branch site.
  • Assure themselves that the legionella risk assessment, water temperatures and running of water outlets is carried out at the branch site.
  • Formalise the system for recording verbal complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at High Street Surgery on 26 January 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example: Disclosure and Barring Service checks or risk assessments for staff who act as chaperones, checking of water temperatures, safe storage of cleaning products and sharps boxes and risk assessments to monitor the safety of the premises.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • We observed that patients could usually get an appointment when they needed one, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by the management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • When employing locum GPs, have systems in place to assure that all appropriate recruitment checks have been carried out, either by themselves or by the locum GP agency.
  • Store cleaning products and used sharps boxes securely within the practice.
  • Carry out a risk assessment regarding chaperones and Disclosure and Barring Service checks.
  • Implement systems for assessing and monitoring risks.

In addition the provider should:

  • Introduce a system to track national patient safety alerts and best practice guidelines through the practice.
  • Clearly define the role of the infection control lead.
  • Check and record water temperatures on a weekly basis as recommended in the legionella risk assessment.
  • Request copies of the necessary recruitment and safety checks for locum GPs from the supplying agency.
  • Complete the outstanding staff appraisals and continue to review annually.
  • Continue to review and update the practice policies and procedures.
  • Implement a system to ensure regular meetings are held within the practice and information discussed at meetings is shared with the appropriate staff members.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice