The Care Quality Commission
  • Doctor
  • GP practice

Crankhall Lane Medical Centre Also known as Crankhall Lane Medical Centre

Overall: Good read more about inspection ratings

156 Crankhall Lane, Wednesbury, WS10 0EB (0121) 531 4704

Provided and run by:
Dr Tehmina Zia Rahman

Important: The provider of this service changed - see old profile

All Inspections

2, 7, 8 September 2021

During a routine inspection

We carried out an announced, follow-up comprehensive inspection at Crankhall Lane Medical Centre on 27 August, 2 September, 7 and 8 September 2021. The practice is rated as good overall and in all key questions.

Following our previous inspection on 13 January 2020, the practice was rated requires improvement overall, inadequate in safe, requires improvement in effective and well-led, good in caring and responsive.

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

Why we carried out this inspection.

This inspection was a comprehensive, follow-up inspection to follow up on:

  • Breaches in regulations relating to safe care and treatment and good governance.
  • A best practice recommendation:

Take action to gain a holistic understanding of data which indicates a low uptake of childhood immunisations as well as national screening programmes such as cervical screening and take action to improve the uptake.

How we carried out the inspection.

Throughout the Covid-19 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 this practice as good overall and good for all population groups except people with long-term conditions which we rated as requires improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • There were systems in place for monitoring patients prescribed high-risk medicines which the provider updated during our inspection to ensure their effectiveness.
  • The practice had put systems in place to improve health outcomes for patients with long-term conditions. We saw unverified data that demonstrated this.
  • We found that cervical screening uptake rates were improving over time due to the actions taken by the practice.
  • The practice had been awarded a gold standard award for the quality of care they provided to patients with a learning disability.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • 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-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Embed into practice the changes made in the monitoring of patients prescribed high-risk medicines or medicines that are subject to Medicines and Healthcare products Regulatory Agency (MHRA) alerts.
  • Continue to take action to improve the uptake of cervical screening.

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

13 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Crankhall Lane Medical Centre on 13 January 2020 as part of our inspection programme.

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.

We rated the practice as inadequate for providing safe services because:

  • The practice had some systems and processes to keep patients safe and protected them from avoidable harm. However, these did not always support the early identification of potential risks.
  • Patients records lacked sufficient information to demonstrate a clear process and audit trail for the management of information about changes to patient’s medicines or GPs involvement in decision making.
  • Significant events were discussed during practice meetings. However, incident forms and practice logs had limited information to demonstrate a thorough investigation to establish root causes to reduce likelihood of reoccurrence.

We rated the practice as requires improvement for providing effective and well-led services because:

  • Quality Outcome Framework (QoF) clinical indicators were below local and national averages for long-term conditions and exception reporting was above local and national averages with no clear clinical reason for this.
  • The practice demonstrated a programme of quality improvement activities such as clinical audits which had been repeated to assess whether improvements had been achieved. However, audits were not targeted at areas where performance showed negative variation and the practice did not operate a process to enable clinical oversight of clinical note keeping or monitoring of the nursing teams’ clinical practice.

  • The practice participated in national priorities and initiatives to improve the population’s health. However, there were variation in the uptake of national screening programmes. The practice demonstrated awareness of this and were taking some action to improve the uptake of cervical screening.

  • Oversight of clinical governance did not support the delivery of safe and effective care. The leadership team did not establish a holistic awareness of issues and areas where performance showed negative variation in order to support development of an action plan to address identified issues. There was a lack of record keeping which impacted on the practice ability to demonstrate safe and effective management of patients care.

  • The practice did not operate an effective governance framework to ensure training updates were routinely completed in an agreed timeframe.

  • There were roles and responsibilities to support the governance framework. However, some areas lacked effective oversight such as the monitoring of training, recording and investigating significant events as well as the accuracy of clinical record keeping.

These areas affected all population groups, so we rated all population groups as requires improvement overall.

We rated the practice as good for providing caring and responsive services because:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

  • The practice had a vision and strategy to deliver care and treatment to their population group. Staff felt supported and able to raise concerns.

The areas where the provider must make improvements are:

  • 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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Take action to gain a holistic understanding of data which indicates a low uptake of childhood immunisations as well as national screening programmes such as cervical screening and take action to improve the uptake.

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