15 June 2023
During an inspection looking at part of the service
We carried out an announced comprehensive inspection at Walsall Wood Health Centre on 15 June 2023 Overall, the practice is rated as requires improvement.
Safe – good
Effective - good
Caring - good
Responsive - requires improvement
Well-led - requires improvement
Following our previous inspection on 2 September 2022, the practice was rated requires improvement overall and for the safe, effective and responsive key questions and rated good for providing caring services and inadequate for providing well-led services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Walsall Wood Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up breaches of regulation from a previous inspection.
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:
- Conducting staff interviews using video conferencing.
- 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 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:
- There had been improvements to the way safe care and treatment was delivered since our previous inspection and governance processes had been strengthened.
- There were improvements to the management of patients’ medicines to ensure appropriate monitoring was in place.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could not always access care and treatment in a timely way and we continued to identify a shortage of appointments with clinical staff.
- We found that there were not always sufficient numbers of suitably qualified and competent persons deployed at all times to provide safe care and treatment.
- Risk management processes were in place, and we found assessments of risks had been completed, however some areas were newly embedded and required further strengthening to ensure risks were mitigated.
We found a breach of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Whilst we found breaches of regulation, the provider should:
- Ensure safety alerts are actioned in a timely way.
- Continue to review the documentation of care records in line with best practice.
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