Walsall Wood Health Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remains unchanged.

The practice had addressed the requirements in the previous breach and staff had now received safeguarding training appropriate to their role and staffing levels had improved. However, at this inspection we found issues relating to good governance, risk management and safe care and treatment.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 mission, vision and values statement which was displayed in the practice and on their website. Their mission was to provide professional, accessible, high quality, comprehensive healthcare services that inspired confidence in their patients and their community. Most staff we spoke with were aware of the mission statement but not all had been involved in the development or the review of this, and not all staff were aware of the vision for the practice. Staff understood the challenges and the needs of people and their communities.

Most staff told us they enjoyed working at the practice. Any changes were discussed during staff meetings and daily communications. Staff told us they were able to offer suggestions for improvement and considered there was a positive culture that ensured people using the service were treated with dignity and respect.

Since the last inspection there had been a change in leadership following the appointment of a new practice manager in January 2024. The practice manager worked across 2 sites. Staff told us they were not always made aware of the days the practice manager was working from the practice but told us they were contactable by phone, and they had access to an assistant practice manager, who had been appointed since the last inspection. Feedback from staff was mixed regarding support, guidance, views being listened to and visibility of leaders.

Leaders had considered succession planning and told us they had very recently appointed a female GP to strengthen the clinical team in addition to an assistant practice manager to provide cover for the practice manager and reception team during annual leave.

Staff shared examples of changes made as a result of staff and patient feedback. These included a change to the working day of clinician in order to benefit patients, and replacement chairs to aid staff comfort at their workstations. A staff member told us they had been very well supported by leaders during a difficult time and had been treated with great care and compassion.

The practice had Freedom to Speak up arrangements in place. Staff had access to a speak up policy and were aware of the designated internal and external leads should they wish to raise a concern, especially in relation to safe care of patients.

Most staff told us they felt supported by leaders and considered their views were listened to and acted upon.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued.

Following changes to the leadership team, defined roles, responsibilities and systems of accountability had been established, however we found these were not fully embedded into practice. Governance systems were not effective in identifying or addressing risk or areas for improvement in addition to general record keeping.

A range of policies and procedures were available; however, we found leaders were not consistently working in line with these and did not always act on the best information about risk, particularly concerning health and safety and staff recruitment and appraisal. The provider had displayed the CQC rating on their website as required in addition to in the practice. However, the poster displayed in the practice was for the 2022 inspection and not the 2023 inspection.

Feedback from staff was mixed regarding the leadership of the practice. Most staff felt the practice had become better led in the previous 12 months but further improvements were required. A member of staff told us they felt the practice was in a better place since the last inspection and considered the provider had taken on board the findings of the last inspection and the practice was moving in the right direction.

Most staff demonstrated an understanding of their individual roles and responsibilities.

Practice meetings were held with staff in addition to appraisals; however not all appraisals had been carried out at the required frequency.

Staff told us they took patient confidentiality seriously; however, we found the security of patient paper records had not been fully considered.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

We spoke with a representative of the Patient Participation Group (PPG). They told us the group had a membership of 5 members. Face to face meetings were held quarterly and chaired by a practice Administrator. They told us good working relationships had been developed, and they found the practice was open and honest and all staff were very helpful and go above and beyond to support their patients. They considered the views of the PPG were listened to and acted upon. For example, they had suggested the practice display their ‘did not attend appointments’ in the waiting area each month so patients could see in addition to a ‘meet the practice team’ board to help patients identify staff and these had been actioned. They told us the practice was patient focused.

There were processes in place to work in partnership with key organisations to support the provision of care and joined up working. The local Integrated Care Board (ICB) and Healthwatch told us they had not received any concerns or feedback about the practice.

The practice was part of Walsall East 1 primary care network (PCN), a larger network of local GP practices working together for the benefit of the local community. The practice manager told us PCN meetings were held quarterly but they would welcome more meetings with their PCN. In addition, practice manager meetings were held locally on a fortnightly basis which provided opportunity to meet and share knowledge. They also advised the practice had developed very good working relationships with the staff at the local pharmacy.

Leaders told us the practice did not provide a GP service to any local care homes.

Leaders told us they were proud of their practice and felt as a small team they were able to cater more to their patients and provide individual attention. They were pleased with how they had achieved in the most recent National GP Patient Survey.

The practice had participated in quality improvement initiatives including the General Practice Improvement Programme (GPIP) in conjunction with the Royal College of General Practitioners to enhance patient experience and satisfaction and reduce pressure on the practice team.

Leaders told us they had recently recruited a female GP via the additional roles reimbursement scheme (ARRS), a program that provides funding to primary care networks (PCNs) to recruit and support roles within the team.

The practice shared some audits they had completed which included antibiotic prescribing for urinary tract infections for patients over the age of 65 in addition to audits on polypharmacy prescribing, inhaler use and pregabalin and gabapentin in order to implement change.

Overall, we found process to support good governance were not operating effectively to drive learning and improvement.