Dudley Wood Surgery

Updated 19 January 2024

Dudley Wood Surgery is located in Dudley, West Midlands:

Dudley Wood Surgery

10 Quarry Road

Dudley

DY2 0EF

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 and surgical procedures.

The practice is situated within the Black Country Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 2,770. 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 ranked as level 3, with one being the most deprived and 10 being the least deprived. According to the latest available data, the ethnic make-up of the practice area is 91% White, 5% Asian, 1% black and 3% Mixed and Other.

The practice is run by a single handed GP (male) and the clinical team includes a part time practice nurse. At the time of our inspection the practice was supported by a locum physicians associate and a further ad hoc locum nurse. The clinicians are supported by a practice manager, a part time clinical coder and three reception/administration staff.

The practice is open between 8.30am to 6.30pm Monday, Wednesday, Thursday and Friday and from 8.30am until 8.30pm on Tuesdays. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. Evening appointments are available as part of the primary care network. Out of hours services are provided by NHS111.

The practice website can be viewed at: www.dudleywoodsurgery.co.uk

Updated 19 January 2024

We carried out an unannounced focused inspection at Dudley Wood Surgery on 9 November 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring – rating of good carried forward from previous inspection.

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 19 November 2020 the practice was rated good overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dudley Wood Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in response to risk and focused on the safe, effective, responsive and well-led domains.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A 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 found that:

• The practice did not have appropriate systems in place for the safe management of medicines. This included an ineffective system for the management of safety alerts, as actions had not been taken to ensure patients were informed of potential risks with certain medicines.
• Patients on high-risk medicines were not always being monitored or reviewed regularly.
• The process for reviewing patients with long term conditions needed improvement to ensure all patients received the appropriate reviews.
• The process for sharing information with the wider practice team needed to be formalised to ensure all staff were included in the sharing of learning outcomes.
• We found safeguarding registers needed strengthening as we were unable to gain assurances that there was effective oversight.
• The practice was unable to demonstrate effective supervision of staff carrying out their roles to ensure they were acting within their competencies.
• There was a lack of induction and oversight for newly appointed staff.
• The overall governance arrangements needed strengthening to ensure there were clear and effective processes for managing risks, issues and performance.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

Whilst we found breaches of regulations, the provider should:

• Take action to increase the uptake of childhood immunisations ad cervical screening.
• Take action to review patients in a timely way where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision is in place.
• Take action to complete basic life support.

As a result of our inspection findings, I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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 Health Care