The Care Quality Commission
  • Doctor
  • GP practice

Harden Blakenall Medical Centre

Overall: Good read more about inspection ratings

The Blakenall Village Centre, 79 Thames Road, Walsall, WS3 1LZ (01922) 927220

Provided and run by:
Modality Partnership

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

All Inspections

31 August 2022

During a routine inspection

We carried out an announced inspection at Harden Blakenall Medical Centre on 31 August 2022, Overall, the practice is rated as Good.

We rated each key question as follows:

Safe - Good

Effective - Good

Caring – Good

Responsive - Requires Improvement

Well-led - Good

Following our previous inspection on 10 March 2020, the practice was rated Requires Improvement overall and for the key questions safe, effective, responsive and well- led but was rated Good for providing caring services. A further inspection was undertaken on 29 June 2021, the practice continued to be rated Requires Improvement overall and for providing effective, responsive and well-led services, the practice was rated Inadequate for safe and Good for caring services. We issued requirement notices for breaches of Regulation 12, Safe care and treatment and Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The full reports for previous inspections can be found by selecting the ‘all reports’ link forHarden Blakenall Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection which included a site visit to follow up on:

  • Breaches of Regulation 12, Safe care and treatment and Regulation 17, Good governance
  • Areas we identified the provider should make improvements, which were to implement comprehensive quality assurance systems to demonstrate the competency of staff undertaking extended roles and ensure information about how to complain was available on the practice website.

How we carried out the inspection.

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 with the aim 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:

  • Requesting evidence from the provider.
  • Conducting staff interviews using video conferencing and telephone.
  • A site visit which included Completing clinical searches on the practice’s patient records system and reviewing patient records.

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 this practice as Good overall and for providing safe, effective, caring and well led services. We have rated the service as Requires Improvement for providing responsive services.

We found that:

  • The practice had comprehensive systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients on high risk medicines.
  • There was a structured and coordinated approach to the management of patients care and treatment including those with long term conditions with effective clinical oversight.
  • The practice continued to perform below the minimum requirements for the uptake of childhood immunisation and cancer screening. The practice was taking action to improve uptake.
  • Staff were provided opportunities for training and development with access to appraisals and supervision. There were assurance systems in place to demonstrate the competency of staff undertaking extended roles.
  • The national GP survey results showed the practice was mostly in line with the local and national average with questions relating to caring.
  • Patients’ experience of accessing the service remained inconsistent. The results of the recent national GP patient survey showed the practice was below the local and national averages for access and overall experience of the service. The practice had taken action to improve and were committed to implementing further changes supported by a structured plan.
  • Information about how to complain was available on the practice website.
  • There was compassionate, inclusive and effective leadership at all levels. Leaders continue to develop capacity and skills with a commitment to delivering high quality, sustainable care.
  • There was clear and effective accountability and oversight to support good governance.

Whilst we found no breaches of regulations, the provider should

  • Continue to review the prescribing rates of medicines that cause serious adverse effects and can be subject to misuse to ensure optimal use of the medicine aligned with patient’s health needs.
  • Continue to monitor and take action to improve the uptake of cancer screening and childhood immunisation.
  • Continue to monitor and take action to improve access and patients experience of the service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

29 June 2021

During a routine inspection

We carried out an announced inspection at Harden Blakenall Medical Centre on 29 June 2021. Overall, the practice is rated as requires improvement.

We rated each key question as follows:

Safe - Inadequate.

Effective - Requires improvement.

Caring – Good.

Responsive - Requires improvement.

Well-led - Requires improvement.

Following our previous inspection on 10 March 2020, the practice was rated requires improvement overall and for the key questions safe, effective, responsive and well- led but was rated good for providing caring services:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Harden Blakenall Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection which included a site visit to follow up on:

  • A breach in Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.
  • Areas we identified the provider should make improvements were, increasing the uptake of cancer screening and childhood immunisation and improving patient satisfaction rates.

How we carried out the inspection.

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 with the aim 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

  • Requesting evidence from the provider.
  • Conducting staff interviews using video conferencing and telephone.
  • A site visit which included Completing clinical searches on the practice’s patient records system and reviewing patient records.

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 this practice as requires improvement overall and for providing effective, responsive and well led services including all the population groups. We have rated the service as inadequate for providing safe services and good for providing caring services.

We found that:

  • The practice did not have reliable systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients on high risk medicines and those with long term conditions.
  • Staff did not always have the information they needed to deliver safe care and treatment.
  • There was a lack of a structured approach to the management of patients care and treatment with limited clinical oversight.
  • The practice was unable to demonstrate an effective systematic and coordinated approach to address areas requiring ongoing improvements, such as cervical screening and childhood immunisation rates.
  • People were not always able to access care and treatment in a timely way. The results of the recent national GP survey showed the practice was below the local and national averages for questions relating to access.
  • The practice did not have fully embedded assurance systems and had not proactively identified and managed risks.
  • There were effective systems and processes in place for recruitment and infection prevention and control.
  • Staff were provided opportunities for training and development with access to appraisals, one to one and clinical supervision. There was a high completion rate for staff training
  • The results of the recent national GP survey showed the practice was mostly similar to the local and national average in questions relating to caring.

We found two breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Implement comprehensive quality assurance systems to demonstrate the competency of staff undertaking extended roles.
  • Ensure information about how to complain is available on the practice website.

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

10 March 2020

During a routine inspection

We carried out an announced comprehensive inspection at Harden Blakenall Medical Centre on 10 March 2020 as part of our inspection programme. On 12 December 2019 we undertook a review of the governance arrangements at provider level and reviewed the corporate policies, procedures and systems in place across the organisation. During this inspection, we looked at whether governance arrangements were embedded and used by staff working at the practice.

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 this practice as requires improvement overall and requires improvement for all population groups.

We rated the practice as requires improvement for safe, effective, responsive and well led services and all population groups because:

  • Staff we spoke with had a good understanding of safeguarding principles, however the safeguarding registers required reviews to ensure they were up to date and appropriate.
  • There were gaps in the practice’s systems for the management of patients on high risk medicines.
  • There were some processes in place to ensure risk assessments were reviewed and maintained, however we found systems needed strengthening to ensure all risks had been identified and acted on to mitigate future risks.
  • Childhood immunisation rates were lower than the national target.
  • Cervical cancer screening results were lower than national targets. The practice encouraged patients to attend their appointments and information was available at the practice on the importance of cancer screening.
  • Patient feedback highlighted the difficulties in telephone access and getting appointments. This was supported by comments received on the day of inspection.
  • The practice was unable to demonstrate that clinical supervision was in place and clinical work was being peer reviewed.

We rated the practice good for providing caring services because:

  • Services were tailored to meet the needs of individual patients. Staff treated patients with kindness, respect and compassion.
  • Feedback from patients highlighted staff were caring and supportive.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Continue to encourage patients to attend cervical screening appointments.
  • Continue with efforts to improve uptake of childhood immunisations and cancer screening overall.
  • Continue to gather patient feedback to improve patient satisfaction scores.

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