• Doctor
  • GP practice

Woodsetton Medical Centre

Overall: Good read more about inspection ratings

40 Bourne Street, Woodsetton, Dudley, West Midlands, DY3 1AF (01902) 883346

Provided and run by:
Woodsetton Medical Centre

Latest inspection summary

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Background to this inspection

Updated 18 January 2017

Woodsetton Medical Centre is a long established practice located in the Woodsetton area of Dudley. There are approximately 6,275 patients of various ages registered and cared for at the practice. Services to patients are provided under a General Medical Services (GMS) contract with NHS England. The practice has expanded its contracted obligations to provide enhanced services to patients. An enhanced service is above the contractual requirement of the practice and is commissioned to improve the range of services available to patients.

The clinical team includes a senior GP partner and two GP partners, a nurse practitioner, two healthcare assistants and a locum practice nurse who supports the practice one day a week. The GP partners and the long term temporary practice manager form the practice management team and they are supported by a senior receptionist, four receptionists and two practice secretaries.

The practice is open between 8am and 6.30pm from Tuesday to Friday with appointments available from 8.50am to 6pm. Extended hours are available on Mondays when the practice offers appointments between 8am and 8pm. Appointments with the locum nurse are available on Mondays between 2pm and 8pm. There are also arrangements to ensure patients received urgent medical assistance when the practice is closed during the out-of-hours period.

Overall inspection


Updated 18 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodsetton Medical Centre on 8 December 2015. Overall the practice is rated as good.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Arrangements were in place to safeguard children and vulnerable adults from abuse that reflected relevant legislation and local requirements.
  • Formal risk assessments had not been completed to assess risks across a number of areas including health, safety and fire. While we observed the premises to be visibly clean and tidy, we found some gaps in the management of infection control.
  • Whilst the practice was trying to recruit for a vacant practice nurse role we noticed some gaps in the provision of the service.
  • The practice did not have a documented business continuity plan in place for major incidents such as power failure or building damage. The practice did not keep up to date records to evidence that there were systems in place to monitor the use of the emergency equipment and emergency medicines
  • Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment.
  • Throughout the inspection process we noticed a theme regarding delays in accessing appointments over the phone.
  • Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised.
  • There were disabled facilities and translation services available.

The areas where the provider must make improvement are:

  • Assess and manage risks associated with health and safety of the premises, fire risk and risk associated with infection control including control of substances hazardous to health and legionella.
  • Ensure emergency medicines and equipment is regularly checked and ensure records are kept to monitor this.

The areas where the provider should make improvement are:

  • Consider the scope of the practice nurse role and continue with recruitment processes to ensure the practice meets the needs and circumstances of people using the service.
  • Develop a plan of business continuity to support the practice in event of a major incident.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

People with long term conditions


Updated 4 February 2016

  • A permanent practice nurse had not been in place since April 2015. The healthcare assistants provided a range of services including asthma and diabetes checks.
  • For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • Performance for overall diabetes related indicators was 98% compared to the CCG average of 88% and the national average of 99%.
  • Flu vaccinations for those patients in the at risk groups was 48%, compared to the national average of 52%.

Families, children and young people


Updated 4 February 2016

  • Childhood immunisation rates for under two year olds ranged from 78% to 100% compared to the CCG averages which ranged from 40% to 100%.
  • Immunisation rates for five year olds ranged from 90% to 95% compared to the CCG average of 93% to 98%.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.

Working age people (including those recently retired and students)


Updated 4 February 2016

  • The practice’s uptake for the cervical screening programme was 76%, compared to the national average of 81%.
  • We found that appointments with the locum nurse were available once a week on a Monday between 2pm and 8pm and therefore patients were limited when accessing nursing services.
  • The practice offered extended hours and telephone consultations for working patients who could not attend during normal opening hours.

People experiencing poor mental health (including people with dementia)


Updated 4 February 2016

  • There were longer appointments available at flexible times for people experiencing poor mental health. However, conversations with staff highlighted that these appointments were only available upon request and not routinely offered to specific patient groups or vulnerable patients.
  • The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.
  • Data showed that diagnosis rates for patients with dementia was 100%, with an exception rate of 0%.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • Performance for mental health related indicators was 100%, with an exception rate of 0%.

People whose circumstances may make them vulnerable


Updated 4 February 2016

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • It offered longer appointments at flexible times for people with a learning disability.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.
  • It had told vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • The practice worked with the local CCG and the Dudley Council for Voluntary Service (CVS) team to improve outcomes for patients in the area. For example,the practice was part of a scheme in the area to help to provide social support to their patients who were living in vulnerable or isolated circumstances.