The Care Quality Commission
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  • GP practice

Archived: Coalpool Surgery

Overall: Good read more about inspection ratings

Harden Road, Walsall, West Midlands, WS3 1ET (01922) 423266

Provided and run by:
Phoenix Primary Care Limited

Important: The provider of this service changed. See new profile

All Inspections

14 February 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Coalpool Surgery on 18 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Coalpool Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 14 February 2017 to confirm that the practice had carried out their plan to meet the required improvements in relation to the breaches in regulations that we identified in our previous inspection on 18 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall, the practice is now rated as good.

Our key findings were as follows:

  • Since our comprehensive inspection, which took place in April 2016 the practice, systems have been implemented to monitor Quality and Outcomes Framework (QOF) performance, the uptake of childhood immunisations and national screening programmes. As a result, the practice has increased the number of under two year olds receiving a vaccination and performance is now higher than the local and national averages.

  • However, when we carried out our follow up inspection we saw that national screening programs such as breast cancer remained below local and national averages.

  • Previously staff we spoke with were unable to provide documentation to evidence that fire drills had been carried out. During the follow up inspection, we saw documents which showed that fire drills had taken place.

  • When we first inspected the practice, some staff we spoke with were not following national guidance when acting as a chaperone. Staff we spoke with as part of the follow up inspection were able to explain how they carried out chaperoning duties. We also saw training records which showed that staff had completed training to enable them to carry out this role within national guidance.

  • When we carried out the comprehensive inspection the practice identified 17 patients as carers, this was 0.41% of the practice list. Since the inspection, the practice had reviewed their carers list. Staff we spoke with during the follow up inspection explained that the practice had identified issues regarding information contained in patients care records. Staff were proactive in asking patients whether they were carers during appointments and when booking appointments. The practice had established a carers’ lead and developed a comprehensive carers’ pack. As a result, the practice had identified 65 patients as carers (4.5% of the practice list).

  • During the comprehensive inspection, data provided by the practice showed that 53% of patients with a learning disability (LD) had their annual health checks in a face-to-face appointments in 2015/16. Since the comprehensive inspection the practice implemented an LD lead, all identified patients had either been sent a letter or contacted via the phone. Despite these efforts, data provided during the follow up inspection showed a 29% uptake rate in 2016/17. Staff we spoke with explained that they were aware of the slow uptake and were planning to offer dedicated Saturday clinic and were exploring ways of targeting patients during school holidays.

  • Since the comprehensive inspection, the practice reviewedareas of their governance arrangements which required improvement. As a result, during the focused inspection we saw that the practice managerial team operated effective systems which enabled them to monitor training needs, staffing levels and communicate clinical audit plans and outcomes. We also saw systems in place, which supported staff to monitor prescription collection.

At our previous inspection on 18 April 2016, we rated the practice as requires improvement for providing effective and well-led services as data provided by the practice showed the uptake of medicine reviews in 2015/16 for patients diagnosed with a learning disability was 53% and the uptake of some national screening programmes were below local and national averages. At this inspection, we found that systems had been established to increase uptake; however, data provided by the practice showed uptake rates remained low. Consequently, there were areas of practice where the provider still should make further improvements.

The provider should:

  • Continue exploring and implementing effective processes aimed at increasing the uptake of annual health checks in a face-to-face reviews for patients with a learning disability.

  • Continue establishing effective measures to encourage patients to engage with national screening programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Coalpool Surgery on 18 April 2016. Overall the practice is rated as requires improvement.

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.
  • There management of uncollected prescriptions was not thorough enough, for example staff were not always following practice policy and procedures.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • The majority of patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment, however not all felt they had sufficient time during consultations.
  • Information about services and how to complain was available and easy to understand. Learning from complaints was shared with staff and other stakeholders.
  • Appointments were available outside of normal hours for example, 7am Mondays and Thursdays, 9am on Saturdays.
  • 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. However there were gaps in governance arrangements and we identified the need to improve record keeping in some areas.
  • The practice was aware of and complied with the requirements of the duty of candour.
  • The practice engaged with the virtual patient participation group and there was a strong focus on continuous learning and improvement at all levels.

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

The areas where the provider must make improvement are:

  • Implement an effective communication system to ensure the results from reviews about the quality and safety of the service and actions taken are shared. For example proposed audits and those which have been carried out by clinicians must be made common knowledge throughout the practice management team.

  • Ensure that staff follow the practice’s policy and procedure when managing uncollected prescriptions.

The areas where the provider should make improvement are:

  • Improve the identification of registered patients who are carers and develop services to meet the needs of these carers.

  • The practice should consider how they could further promote childhood immunisations and screening.

  • Extend the review of processes to increase the number of patients who take part in the bowel and breast screening programme.

  • Increase the number of patients identified with a learning disability who have had a their medication reviewed in the last 12 months.

  • Ensure that they maintain a log of fire drills that have been carried out by the property landlords and continue seeking to obtain completed cleaning schedules.

  • Ensure that staff are aware and clear of lead roles, for example the practice should ensure that all staff are aware of who the infection prevention control lead is within the practice.

  • Ensure that all non clinical staff follow national guidance when acting as chaperones.  

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice