The Care Quality Commission
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Lower Gornal Medical Practice

Overall: Requires improvement read more about inspection ratings

Bull Street,, Lower Gornal,, Dudley, West Midlands, DY3 2NQ (01384) 322422

Provided and run by:
Lower Gornal Medical Practice

All Inspections

During an assessment under our new approach

Date of Assessment: 27 June 2025 to 2 July 2025. Lower Gornal Medical Practice is a GP practice and delivers service to 8015 patients under a contract held with NHS England. Information published by Office for Health Improvement and Disparities shows deprivation within the practice population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

Staff and managers demonstrated an understanding of risk management; however, several processes required strengthening. These included oversight of staff immunisations, staff training, governance around non-medical prescribers, medicines management and safeguarding processes.

People were generally involved in the assessment of their needs, although mechanisms to support this process needed to be better aligned with current evidence and best practice. Care was consistently delivered with kindness and compassion, and staff upheld patients’ privacy and dignity.

Feedback from patients and staff indicated that access to care and treatment was timely and responsive to individual needs. While services were designed with patient care in mind, leaders did not consistently demonstrate the experience, capacity, or capability necessary to ensure that the organisation’s strategic vision and risks were effectively managed.

Staff reported feeling supported in their roles; however, there was no established system for regularly communicating and sharing learning or best practice, which limited opportunities to enhance governance and foster continuous improvement.

We found breaches of regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

21 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of Lower Gornal Medical Practice, in March 2016. As a result of our comprehensive inspection a breach of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified areas where the provider must make improvement and an area where the provider should improve.

We carried out a focussed desk based inspection of Lower Gornal Medical Practice on 21 December 2016 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lower Gornal Medical Practice on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:

  • As part of our desk based inspection we noted improvements in the arrangements to deal with medical emergencies.
  • For example, since our comprehensive inspection took place in March, the practice effectively mitigated risk in the absence of specific emergency medicines and medical emergency equipment. We saw evidence to confirm that the practice had a defibrillator in place and had purchased specific emergency medicine associated with minor surgery and the procedure of fitting specific birth control devices.
  • When we inspected the practice in March we found that fridge temperatures were not appropriately recorded in line with guidance by Public Health England. As part of our desk based inspection the practice shared records to demonstrate that fridge temperatures were appropriately recorded.
  • When we inspected the practice in March, some patients we spoke with commented that occasionally conversations could be heard at the reception desk, this was due to the open plan reception and waiting area.
  • As part of our desk based inspection we saw copies of notices displayed to confirm that patients were advised that they could use a private area for private discussions and to speak to a member of staff if this was required. The practice manager also confirmed that reception staff were aware to offer a private area to patients who wanted to discuss sensitive issues or appeared distressed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lower Gornal Medical Practice on 1 March 2016. 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.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance
  • Staff were aware of their responsibilities to raise and report concerns, incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment
  • Staff we spoke with said they felt valued, supported and that they felt involved in the practices plans.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.
  • We observed the premises to be visibly clean and tidy. Information for patients about the services available was easy to understand, accessible and available on a variety of formats.
  • The practice offered proactive care to meet the needs of its population.
  • The practice proactively sought feedback from staff and patients, which it acted on. The practice had an active patient participation group which influenced practice development.

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

The areas where the provider must make improvements are:

  • Ensure fridge temperatures are recorded correctly, in line with national guidance, to ensure robust maintenance of the cold chain.
  • Ensure risk is assessed and mitigated in the absence of specific emergency medicine associated with minor surgery and the procedure of fitting specific birth control devices.
  • Ensure risk is mitigated in the in the absence of emergency medical equipment such as the defibrillator.

The areas where the provider should make improvement are:

  • Ensure systems are in place to inform patients that a private area is available for private discussions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice