The Care Quality Commission
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  • GP practice

Archived: Lakeside Medical Centre

Overall: Good read more about inspection ratings

Church Road, Perton, Wolverhampton, West Midlands, WV6 7PD (01902) 755329

Provided and run by:
The Royal Wolverhampton NHS Trust

Important: The provider of this service changed. See old profile

All Inspections

23 July 2021

During an inspection looking at part of the service

We carried out a desk based announced inspection review at Lakeside Medical Practice on 23 July 2021. Overall, the practice is rated as good.

Ratings for each key question:

Safe – Good

Effective – Good (rating carried forward from February 2019 inspection)

Caring – Good (rating carried forward from February 2019 inspection)

Responsive – Good (rating carried forward from February 2019 inspection)

Well Led – Good (rating carried forward from February 2019 inspection)

Lakeside Medical Centre was previously inspected in April 2016 and was rated good overall. A comprehensive inspection carried out in February 2019 as part of our inspection programme rated the practice as good overall and for all population groups but requires improvement for providing safe services.

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

Why we carried out this review

This inspection was a focused review of information to follow up on:

  • The key question of Safe, which was rated as requires improvement at the last inspection in February 2019.
  • Areas followed up at this inspection included breaches of regulations and ‘shoulds’ identified at the previous inspection. We identified issues related to staff recruitment, staff immunisation, emergency medicines and equipment, health and safety and the completion of relevant staff training and effective monitoring of risks.

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 reviews differently.

This inspection was carried out in a way which enabled us to not have to undertake an onsite visit. 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
  • Requesting evidence from the provider

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

We found that:

  • The provider had put systems in place to ensure that all staff could receive vaccinations and immunisations relevant to their role and that information related to staff immunisation status was recorded.
  • Staff files contained the required information to demonstrate recruitment systems had been reviewed.
  • Risk assessments had been completed for the safe storage and handling of hazardous substances used at the practice.
  • Notices were displayed to identify the fire marshals easily and details were included in local procedures and training certificates were seen to show that staff had been trained for the role.
  • Risk assessments had been completed to mitigate any risk of potential scalding or burning from the surface of radiators in consulting rooms, which had been identified as hot to touch.
  • Ongoing reviews of emergency medicines was taking place to ensure individual GP practices within the provider primary care network held emergency medicines that were appropriate to the patient services they provided.
  • The provider had replaced the emergency equipment / medicine trolley with grab bags. This change provided staff with easier access to emergency medicines and equipment.
  • Procedures for the management of equipment used at the practice had been reviewed and updated to ensure the equipment was regularly calibrated and maintained. This included the action to be taken to dispose of equipment that was not working or had been condemned.

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

12 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Lakeside Medical Centre on 12 February 2019 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 good overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • The practice could not demonstrate that all staff received vaccinations and immunisations relevant to their role and that information related to staff immunisation status was recorded.
  • The practice could not demonstrate that safe recruitment practices were completed for all staff.
  • The practice did not have all the recommended emergency medicines available at the practice and had not completed risk assessments.
  • Emergency medicines were not all immediately accessible to staff because they were stored in different areas of the practice.
  • There was a lack of records to demonstrate that the provider had ensured that all staff were up to date with immunisations relevant to their role.
  • Fire marshals were not named in the fire safety policy and evidence that they had been trained for the role was not available.
  • A risk assessment had not been completed for radiators to mitigate any risk of potential scalding or burning.
  • The provider had not taken prompt action to replace the defibrillator that was not working or put a risk assessment in place to mitigate any level of risk while waiting for a decision.

We rated the practice as good for providing effective, caring, responsive and well led services because:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. 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-centre care.

The areas where the provider must make improvements are:

  • Care and treatment must be provided in a safe way for service users.

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