Walsall Wood Health Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a process for reporting and recording significant events. Staff we spoke with demonstrated an understanding of this process and were able to recall an event and the action taken.

Nine significant events had been recorded in the last 12 months. A significant event log was shared with us during our site visit. However, it was difficult to cross reference the log with the records kept on file as they were not easily identifiable and some of the significant event records were missing from the file. This was discussed with leaders, who were later able to produce the missing records and numbered the significant events to help with identification. From examining 3 records, we found that they were not always managed effectively. For example, the forms had not always been signed and dated and lacked detail including learning and quality improvement. We found that 1 of the events had not been discussed during the practice’s monthly meeting and had not been shared with the wider team for learning to help prevent it happening again.

There was a system for recording and investigating complaints. Patients had access to the complaint’s procedure, which was available on display at the practice and also available on the practice website. Leaders confirmed no formal complaints had been received in the previous 12 months, 13 verbal complaints had been received and logged.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. The practice told us for continuity of care; they offered patients appointments with the same clinician where appropriate.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. The practice had a designated safeguarding lead and deputies in place for staff to escalate any concerns to. Safeguarding concerns were shared and discussed in staff meetings held.

At the last inspection, we found that not all staff had received the appropriate level of safeguarding training required for their role. At this assessment, we found staff were now trained in safeguarding procedures to the appropriate level.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Two clinicians shared examples of the action taken when they had safeguarding concerns, which were escalated externally and since resolved.

There were arrangements in place to ensure registers were reconciled with the local authority to make sure they were appropriately maintained. Meetings were held monthly to discuss vulnerable patients, including patients nearing end of life.

The practice worked with people to understand and manage risks. They provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated

The practice held medicines in the event of a medical emergency, and these were securely stored. Emergency equipment was available and maintained with the exception of 2 items. A risk assessment had been completed for 1 of the items and a risk assessment for the other item was later shared with us following our site visit. Checks were carried out on the medicines and equipment held but not at the required frequency, as recommended by the Resuscitation Council UK (RCUK). Following our site visit the provider sent us a policy they had since developed covering the frequency for checks on equipment and training as per the RCUK guidance.

The service was provided from a converted semi-detached property, providing 3 consultation rooms on the ground floor and 2 staff offices on the first floor. Staff told us due to the constraints of the building they were limited with the services they were able to offer. Leaders told us they recognised their responsibility in maintaining a safe environment ensuring that facilities were clean, well-maintained, and fit for purpose, with documented inspection and maintenance processes.

The practice had a designated member of staff responsible for health and safety in addition to a written policy. We found the service did not always detect, assess or manage potential risks in the care environment effectively to ensure equipment, and facilities supported the delivery of safe care. The premises were leased from a landlord. Leaders shared the challenges they had with ensuring the works to address potential risks were actioned and addressed promptly.

We saw a range of maintenance, service checks and risk assessments had been completed. However, some had identified potential risks. These included legionella, electrical installation, fire alarm systems and fire safety measures. Leaders told us remedial action in relation to the electrical work to reduce the risk of fire was due to be undertaken during the weekend of 18 October 2025. The Care Quality Commission (CQC) received confirmation on 16 November 2025 that the required actions had since been completed on 24 October 2025 to ensure full compliance with all identified risks.

The practice was not working in line with their health and safety policy in pro-actively identifying slip and trip risks in the workplace and eliminating these risks where possible. We found not all environment risks had been identified or actioned, for example trip hazards in the staff offices due to the worn and uneven carpets.

Areas of the practice we observed looked tired and the window in one of the staff offices could not be opened as it was broken. The practice manager confirmed there was no established schedule for renewal or refurbishment in place for the replacement for floor coverings, the redecoration of the premise and replacement of furniture and furnishings. Following the site visit the practice sent us a copy of their renewal and replacement of fixtures and fittings policy and trip hazards in staff office policy. However, they were not working in line with these policies, which stated items must be renewed or replaced if they are damaged, broken, or unsafe or creating potential trip, slip, or electrical hazards. The patient participation group (PPG) had also commented on the appearance of the practice internally and externally and this had been raised in the most recent PPG and practice meeting held.

We also observed patient paper records were not stored securely to prevent unauthorised access as they were stored on open shelving in the reception office, which led up to staff offices on the first floor. The room was cleaned by an external cleaner when the practice was closed. We were told a risk assessment had not been completed to mitigate the risk of breaches to patient confidentiality. Following our site visit a mitigation plan was later shared with us, however we could not be assured that the arrangements to mitigate risks were satisfactory or being adhered to.

There was a business continuity plan in place which was monitored and reviewed.

The practice employed a team of 8 staff in clinical and non-clinical roles. Patients had access to a nurse associate, paramedic and pharmacists provided through the Primary Care Network. Staff felt there were enough staff to meet people’s individual needs. Leaders told us they had no current staff vacancies.

Staff told us they received support and development opportunities. Although not all staff felt they had received enough specific training for their role. We found essential training was up to date, learning needs and development of staff was managed, and staff were working within their agreed areas of competence. One clinician told us they were booked to attend a training course to upskill their knowledge in respiratory conditions.

Leaders told us new staff received an induction to their role. However, staff records we sampled showed their induction was not always appropriate to their role. For example, a non-clinician had completed an induction not relevant to their work. No evidence of completed induction was available on file for the regular locum GP to ensure they had the necessary information to provide safe and consistent patient care. Following our site visit the provider sent us their locum GP induction policy and told us an induction pack was held in the consulting room.

There were arrangements in place to review the effectiveness of the consultations and safe prescribing for the locum GP, clinical pharmacists and the paramedic. These were recorded and included feedback and any identified actions for improvement.

Staff had received appraisals; however, these had not always been completed annually. Records sampled were incomplete or basic and did not include agreed objectives or future goals and training needs. Staff probationary reviews were not available or incomplete on the files we sampled. Following our site visit, the provider told us appraisals had since been forward planned and diarised to ensure they were always held on time.

Staff files we sampled were well presented. However, the practice was not working in line with their recruitment policy and did not have the appropriate processes in place for assessing and checking staff offered employment were fit and proper persons. We saw a risk assessment had been completed for 1 staff member in the absence of a disclosure and barring service (DBS) check; however, records showed it took 14 months to obtain a DBS check. A DBS check for another staff member had been completed post their start date and no risk assessment had been completed. One reference had been obtained for the regular locum GP; however, this was dated 14 months post their start date and their contract was dated 18 months post their start date. The recruitment records for a locum GP who was due to commence working at the practice a couple of days after our site visit were not available for inspection. We were told these were at the provider’s other GP practice, but all of the required checks had been undertaken.

Following our site visit the practice sent us copies of the assurances they had obtained from their Primary Care Network (PCN) confirming that the required recruitment checks for all staff working at the practice employed under the Additional Roles Reimbursement Scheme (ARRS) had been undertaken and these staff had completed all required training.

The practice had an infection, prevention and control (IPC) policy and a designated infection, prevention and control (IPC) lead. All staff had received relevant training and had access to personal protective equipment. An internal infection control self-assessment audit had been undertaken in April 2025 in addition to an external one in 2024. Actions had been taken to mitigate risks; however, we found IPC processes were not always effective.

The internal audit did not identify staff offices on the first floor were carpeted and stated bins were emptied daily. During a tour of the practice, we saw bins in public areas were full and cleaning mops, although colour coded, were not stored appropriately and posed the risk of cross infection. This was rectified during our visit. Due to the constraints of the building and the availability of storage space, we found rooms were cluttered and therefore not easy to clean. Cleaning schedules were in place however, these failed to include the deep cleaning, including carpeted areas within staff offices. Adequate arrangements were not in place to ensure the practice maintained a satisfactory level of cleanliness at all times. An external company was employed and provided just 6 hours of cleaning a week over 2 days. Staff were responsible for cleaning their own rooms and felt the practice would benefit from additional cleaning hours provided externally. Following our site visit the provider told us they had added a deep clean to the cleaning schedule and for bins to be emptied daily.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

The refrigerator used to store vaccines and medicines was monitored twice daily to ensure temperatures were maintained and products were appropriately stored within them. The practice also used a data logger to monitor the fridge temperatures, and the data was downloaded weekly or if there were any concerns about the fridge temperatures falling out of range. Staff managed prescription stationery appropriately and checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

On the whole, staff followed protocols to ensure they prescribed most medicines safely. The majority of people whose records we sampled had received the recommended medicines reviews and monitoring was mainly completed within correct intervals. However, these reviews were not always effective. For example, we found there were issues with overuse of asthma rescue inhalers and 1 patient was prescribed a specific medicine which was contraindicated. This was not identified at the patient’s annual asthma or medication reviews.

No concerns were identified in relation to the monitoring of patients’ prescribed medicines to treat conditions, including rheumatoid arthritis, those with hypothyroidism (under active thyroid) or with a chronic kidney disease. We found monitoring was overdue for a small number of patients prescribed blood thinning medicines, however the majority had received monitoring at the correct intervals. The practice was aware of these patients that were overdue their monitoring and had taken action to recall these patients and ensure medicines were not prescribed without the required monitoring.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

We reviewed a sample of the patient group directions (PGDs), (written instructions to help qualified health professionals supply and administer medicines to patients). We found all were valid.

There were systems in place to manage and respond to safety alerts and medicine recalls and an electronic log of alerts was maintained. We found alerts were generally addressed. Our clinical searches found the practice had taken action to address risks identified in the alerts we sampled but the documentation on patient records could be improved. Staff spoken with were aware of the process for the management of these.

A range of clinical audits of prescribing practices had been carried out that focused on improving care and treatment. Prescribing data reviewed as part of our assessment found the practice performance was higher than national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain); psychotropic medicines (used to treat various mental health conditions); hypnotic drugs (used for the management of severe insomnia); and antibiotics. Clinicians spoke with were aware of the practice prescribing data. They told us this had been discussed during a meeting held, and they were raising awareness with patients, particularly around appropriate antibiotic use and resistance and were actively trying to deprescribe gabapentinoids and had been reviewing patients prescribed these medicines.