Background to this inspection
Updated
3 November 2021
Pinfold Medical Centre is located at:
Field Road
Bloxwich
Walsall
WS3 3JP
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.
The practice is situated within the Black Country and West Birmingham Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS). This is part of a contract held with NHS England.
Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.
The National General Practice Profile states that 94% of the practice population is from a white ethnic background with a further 6% of the population originating from black, Asian, mixed or other non-white ethnic groups.
The practice has three registered GP partners (two male and one female), and seven GP’s who are long term locums (one male and six female), one female advanced nurse practitioner, one female practice nurse, three female healthcare assistants, an advanced clinical pharmacist, two practice managers and a team of administrative and reception staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of appointment.
The practice is open between 7.30am and 6.30pm from Monday to Friday. When the practice is closed patients are directed to the out of hours provider via the NHS 111 service. Patients also have access to the Extended GP Access Service between 6.30 pm and 9pm on weekdays, 10am to 3pm on weekends, and 11 am to 1.30pm on bank holidays. Out of hours services are provided by West Midlands Ambulance Service via NHS 111.
Updated
3 November 2021
We carried out an announced inspection at Pinfold Medical on 20 and 29 September 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring – Good
Responsive - Good
Well-led - Good
Following our previous inspection on 3 and 6 March 2020, the practice was rated Requires Improvement overall. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pinfold Medical on our website at www.cqc.org.uk
Why we carried out this inspection/review
This was a focused inspection to follow up on:
- The safe, effective and well-led key questions
- Any breaches of regulations or ‘shoulds’ identified at our last inspection.
Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive.
How we carried out the inspection/review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated the practice as Good overall with the exception of People experiencing poor mental health (including people with dementia) which we rated as Requires Improvement.
We found that:
- There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
- Patients received effective care and treatment that met their needs.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment. There was clinical oversight and effective systems for quality improvement.
- Although the practice remained below the threshold for long term condition reviews and cervical screening rates, they were able to evidence that an action plan was underway to improve outcomes with progress monitoring in place.
- Mental health indicators were below local and national averages which had declined further since our last inspection and action taken had not yet demonstrated improved outcomes.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Although our clinical searches identified some issues with high risk medicine management, these issues were not systemic, and the provider demonstrated they had the capacity and capability to address them.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. There were systems and processes in place for the recruitment of staff in accordance with the regulations.
- We found health and safety, fire safety risk assessment, security risk and infection control assessments had been completed at the practice premises.
Whilst we found no breaches of regulations, the provider should:
- Continue to strengthen processes for the reviewing high risk medicine and actioning of safety alerts.
- Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
- Continue with steps to review those patients with long term conditions.
- Continue to increase the uptake for cervical, breast and bowel screening.
- Continue with steps to engage with a patient participation group.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care