The Care Quality Commission
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Archived: Blakenall Family Practice

Overall: Good read more about inspection ratings

Blakenall Village Centre, 79 Thames Road, Walsall, West Midlands, WS3 1LZ (01922) 443729

Provided and run by:
Phoenix Primary Care Limited

Important: This service was previously managed by a different provider - see old profile

All Inspections

25 April 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 Blakenall family Practice on 4 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Blakenall Family Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 April 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 4 July 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; however continues to be rated as requires improvement for providing responsive services.

Our key findings were as follows:

  • At our July 2016 inspection, some medicines required to respond to medical emergencies were not stored within the practice and the provider had not assessed the risk posed by the absence of these. During this inspection we found that the arrangements to respond to medical emergencies had been strengthened.

  • Results from the national GP patient survey published in July 2016 showed that patient satisfaction had slightly improved in some areas and declined in others since the July 2016 inspection. The practice was aware of this and taking action to improve patient satisfaction.

  • Previously we saw the practice complaints process was not being followed effectively. As part of this inspection, we saw that oversight of the complaints process was more effective. As a result, the practice responded to complaints in a timely manner and improvements were made to the quality of care as a result of complaints and concerns.

  • Arrangements for monitoring and improving quality and managing risk had improved since our previous inspection. For example, the practice established a programme of continuous clinical audits and oversight of risk was managed effectively.

  • Data from the 2015/16 quality outcomes framework showed uptake of childhood immunisations was below local and national averages for vaccinations given to under two’s and five year olds. Staff we spoke with during this inspection explained that they actively contacted patients who failed to attend appointments.

  • The practice no longer had set immunisation clinics and made clinic times more flexible for patients. Staff explained that the practice was also involved in a pilot with child health aimed at gathering central data of completed immunisations. As a result, 2016/17 QOF data showed immunisation uptake for under two’s and five year olds was above local and national averages.

  • As part of the previous inspection data from the March 2015 national cancer intelligence network showed that uptake for breast and bowel screening was below local and national averages. When we carried out this inspection, we saw that uptake remained below local and national averages; however the practice were aware of this and continued to take actions to improve uptake. This included actively contacting patients to encourage uptake and arranging for testing kits to be sent out directly to patients.

In addition the provider should:

  • Continue to review national GP patient survey results and internal patient feedback; and explore effective ways to improve patient satisfaction.

  • Continue to consider effective ways of encouraging the uptake of national screening programmes such as bowel and breast cancer.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

04 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We initially inspected Blakenall Family Practice in September 2015 and was rated as requires improvement overall and requires improvement for providing safe, effective, caring and well-led services.

At this previous inspection, we found that the provider was not taking action to mitigate risks relating to the health and safety of patients receiving care and treatment. The procedure in place for acting on patients test results was not effective. The provider had not taken proactive action to improve the uptake of childhood immunisations. The provider did not act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services. The provider had not acted on feedback from patients including the national GP survey and the practices own survey. As a result, the provider was issued with requirement notices relating to safe care and treatment; and good governance.

Following the inspection the provider sent us an action plan detailing the action taken to ensure compliance with the regulations. We reviewed the action plan as part of the inspection on 4 July 2016.

We then carried out an announced comprehensive inspection at Blakenall Family Practice on 4 July 2016 to ascertain whether the required improvements had been made; we found that some of the improvements had been made. Overall, the practice is rated as requires improvements.

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

  • Risks to patients were not always robustly assessed and well managed. For example in the absence of some emergency medicines, the practice had not carried out a risk assessment to mitigate identified risks. Following the inspection the practice informed us that an appropriate risk assessment had been carried out and appropriate action taken to mitigate against future risks.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • Although multidisciplinary working was taking place this was generally, informal and record keeping was limited or absent.

  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, although there was an increase in uptake for national screening programs this remained below national and local average.
  • Although patients we spoke to on the day said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment, results from the national GP patient survey identified less positive feedback. Action was being taken to address this.
  • Information about services and how to complain was available and easy to understand. However, the practice was not consistently responding to patients within their recommended timeframes. Meetings were held to discuss complaints with staff however; documentation of a thorough analysis and learning was limited.
  • Patients said they found it difficult to make an appointment with a named GP and were seeing different GP therefore felt there was no continuity of care, although urgent appointments were available the same day. An internal patient survey carried out showed that patients found it easy to get an appointment with the GPs.
  • 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 management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The practice had a number of policies and procedures to govern activity, however in some areas, there were weaknesses in the monitoring of procedures and the management of some risks.

The areas where the provider must make improvement are:

  • Carry out a risk assessment in the absence of emergency medicines required to respond to epileptic seizures and take appropriate action to mitigate identified risks.

  • Review the complaints process to ensure complaints are managed in line with national guidance and practice policy.

The areas where the provider should make improvement are:

  • The provider should consider how they ensure that actions from multidisciplinary meetings are captured and completed in the absence of minutes.

  • Continue developing and formalising their plans to strengthen their clinical audit cycle.

  • Continue to respond and review patient feedback, including the national GP patient survey in order to further improve patient satisfaction.

  • Continue taking proactive measures to improve the uptake of childhood immunisations and continue with efforts to engage the practice population with national screening and immunisation programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

08 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Blakenall Family Practice on 8 September 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective, caring, and well led services. We found the service to be good for providing responsive services. The areas for improvements that led to these ratings also applied to all of the six population groups that we inspected which are:

  • Older people
  • People with long term conditions
  • Families, children and young people
  • Working age people (including those recently retired and students)
  • People whose circumstances may make them vulnerable
  • People experiencing poor mental health (including people with dementia).

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

  • Staff understood and fulfilled their responsibilities to raise safety concerns, and to report incidents and near misses. Risks to patients were assessed and managed, with the exception of the management of prescriptions taken for home visits and risks associated with staff who do not have a disclosure and barring service (DBS) check in place. Not all significant events were recorded to ensure a detailed analysis of the event.
  • There were arrangements in place to identify, review and monitor patients with long term conditions. Patients’ needs were assessed and care was planned and delivered following best practice guidance. However, procedures in place for reviewing patients’ test results were not effective. There was scope to improve the uptake of childhood immunisations.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, data showed the practice was performing significantly below local and national averages in a number of areas including being treated with care and concern. The practice had not taken effective action to address the improvements identified.
  • The practice was responsive to the needs of its patient population. There were services aimed at specific patient groups. The practice had good facilities and was well equipped to treat patients and meet their needs. Information about services and how to complain was available and the practice responded quickly to issues raised. However, data showed the practice was performing significantly below local and national averages in a number of areas including access to appointments and getting through on the telephone.
  • There was clear leadership and staff felt supported by management. The practice had a number of policies and procedures to govern activity and there were regular meetings to share information with staff. However, the governance arrangements at the practice were not robust as not all risks were assessed and managed. The practice had not acted on feedback from patients to improve the quality of the service.

The areas where the provider must make improvements are:

  • Review the procedure in place for acting on patients test results to ensure that it is effective.
  • Act on feedback from patients to improve the quality of the service. This includes areas of improvement identified in the 2015 national GP patient survey.

The areas where the provider should make improvements are:

  • Consider how significant events are recorded to enable a detailed analysis to take place.
  • Consider further action to improve the uptake of childhood immunisations.
  • Develop a system to ensure a clear audit trail for paper prescriptions taken for home visits.
  • Risk assess staff who do not have a disclosure and barring service (DBS) check in place.
  • Complete clinical audit cycles in order to demonstrate improvements made to patient outcomes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice