The Care Quality Commission
  • Doctor
  • GP practice

Lockfield Surgery

Overall: Good read more about inspection ratings

Croft Street, Willenhall, West Midlands, WV13 2DR (01902) 639000

Provided and run by:
Dr Shadia Zaki Abdalla

All Inspections

28 July 2022

During a routine inspection

We carried out an announced inspection at Lockfield Surgery on 28 July 2022. Overall, the practice is rated as Good.

We rated each key question as follows:

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

The service was last inspected on 29 November 2021 and rated Inadequate overall. Following the inspection, we took enforcement action against the provider and issued warning 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 service was placed in special measures.

An announced focused inspection was carried out on 29 March 2022 and included a site visit to confirm that the provider had carried out their plan to meet the legal requirements in relation to the warning notices issued. At this inspection in March 2022 we found the practice had taken the action needed to comply with the legal requirements of the warning notice we issued.

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

Why we carried out this inspection

This was a comprehensive inspection which included a site visit to review all of the key questions, assess if the practice could be removed from special measures and update the provider’s rating.

How we carried out the inspection

Throughout the pandemic Care Quality Commission (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

We found that:

  • Systems and processes were embedded to ensure risks were assessed and managed.
  • 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. Plans were in place to assess all patients due a medicine review prioritising high risk patients, however since November 2021 less than half of those who required a review at that time had received one.
  • There was a structured and coordinated approach to the management of patients care and treatment including those with long term conditions. The practice was proactive in following up and responding to patients who did not attend.
  • The practice continued to achieve below the minimum requirements for cancer screening. The uptake of childhood immunisations, although improved. was below the World Health Organisations target . However, we found the practice was taking appropriate action to improve uptake.
  • Staff were provided opportunities for training and development with access to appraisals and clinical supervision. Staff described a positive culture with practice wide learning encouraged and supported.
  • The results of the recent national GP survey showed the practice was mostly above the local and national average in questions relating to caring and accessing the service. The practice had consistently performed well in these areas.
  • There was compassionate, inclusive and effective leadership at all levels. Leaders had developed 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 take action to review all patients due a medicine review ensuring these are completed in a timely manner.
  • Continue to monitor and take action to improve the uptake of cancer screening and childhood immunisation.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this 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 March 2022

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Lockfield Surgery on 29 November 2021. Overall, the practice was rated as inadequate. This rating will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report. Following the inspection, we took enforcement actions against the provider and issued a warning notice for breaches of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014, Safe care and treatment.

The full comprehensive report on the November 2021 inspection can be found by selecting the ‘all reports’ link for Lockfield Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was an announced focused inspection carried out on 29 March 2022 and included a site visit to :

  • Confirm that the practice had carried out their plan to meet the legal requirements in relation to the warning notices issued.
  • This report only covers our findings in relation to those requirements.

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

  • 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 found that:

  • The practice had taken the action needed to comply with the legal requirements of the warning notice we issued.
  • There were improvements to systems and processes to assess, monitor and manage risks to patient safety, including recruitment, fire, infection prevention and control and safeguarding.
  • The practice had taken action to improve oversight of care records and clinical data to address gaps and inconsistences identified at the last inspection.
  • Reliable systems were in place for the appropriate and safe use of medicines. This included the monitoring of patients on high-risk medicines and those with long term conditions. There were structured plans in place to ensure that all outstanding patients were reviewed and the practice was prioritising patients based on risk.
  • Patients with long term conditions were monitored and reviewed. The practice was proactive in following up and responding to patients who did not attend.
  • The practice had developed a comprehensive quality assurance system to assess the quality and safety of the service.
  • Leaders had developed capacity and skills with a commitment to deliver high quality, sustainable care.
  • The provider had improved the system used to assess and monitor the governance arrangements..
  • A review and risk assessment of the premises had been completed with plans in progress to ensure necessary repairs and upgrades were completed.
  • An induction loop system was available at the practice to support patients with a hearing impairment.
  • Information about how to complain was available on the practice website and final responses to complaints included details of action to take if the patient was not happy with the findings.

The areas where the provider should make improvements are:

  • Continue to take action to review all outstanding patients in receipt of high-risk medicines to be able to demonstrate appropriate monitoring is in place.
  • Continue to take action to review all outstanding patients due a structured medicine review.
  • Review the systems and processes to keep clinicians up to date with current evidence-based practice to be able to demonstrate that changes in guidelines are consistently reflected in care and treatment.

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

29 November 2021

During a routine inspection

We carried out an announced inspection at Lockfield Surgery 29 November 2021. Overall, the practice is rated as inadequate.

We rated each key question as follows:

Safe - Inadequate.

Effective -Inadequate.

Caring – Good.

Responsive - Good

Well-led - Inadequate.

Why we carried out this inspection

This inspection was a comprehensive inspection which included a site visit to:

  • Rate the service following registration as a new provider.

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

  • 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.

The overall rating for this practice is inadequate. The reason for this is that although our ratings of caring and responsive services is good, the provision of safe, effective and well-led services are rated as inadequate.

We found that:

  • There were gaps in systems to assess, monitor and manage risks to patient safety, including recruitment, fire, infection prevention and control and safeguarding. Risk assessments were not always in place, adequately reviewed or lacked detail to mitigate potential risks.
  • 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 no systematic structured approach with effective clinical oversight of patient information including clinical data.
  • The practice was unable to demonstrate that it consistently acted on safety alerts.
  • The practice was below national averages for cancer screening and the uptake of childhood immunisations.
  • Comprehensive quality assurance systems were not in place to demonstrate the competency of staff undertaking advance clinical practice.
  • The practice did not have fully embedded assurance systems and had not proactively identified and managed risks.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • There was a lack of leadership oversight and the absence of comprehensive systems and processes to monitor the quality and effectiveness of the service and the care provided.
  • There was no formal system in place to assess and monitor the governance arrangements in place.
  • Staff described a positive culture with practice wide learning encouraged and supported.
  • The results of the recent national GP survey showed the practice was mostly above local and national average in questions relating to caring and accessing the service.

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:

  • Review the premises to ensure necessary repairs and upgrades are completed.
  • Ensure an induction loop system is available at the practice to support for patients with a hearing impairment.
  • Ensure information about how to complain is available on the practice website and final responses to complaints includes details of action to take if the patient is not happy with the 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 Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care