The Care Quality Commission
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  • GP practice

Coalway Road Medical Practice

Overall: Good read more about inspection ratings

117-119 Coalway Road, Penn, Wolverhampton, WV3 7NA (01922) 339296

Provided and run by:
The Royal Wolverhampton NHS Trust

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

All Inspections

15 June 2021

During an inspection looking at part of the service

We carried out a desk based announced inspection review at Coalway Road Medical Practice on 15 June 2021. Overall, the practice is rated as good.

Ratings for each key question:

Safe – Good

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

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

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

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

Coalway Road Medical Practice was previously inspected in May 2015 and was rated good overall. A comprehensive inspection carried out in December 2017 as part of our inspection programme rated the practice as requires improvement for providing safe, effective and well led services and the practice was rated requires improvement overall. A further inspection was carried out in August 2019, the practice was rated good overall and requires improvement for providing safe services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Coalway Road Medical Practice 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 August 2019.
  • Areas followed up at this inspection included breaches of regulations and ‘shoulds’ identified at the previous inspection. These were related to the safe prescribing and monitoring of high risk medicines and the lack of effective systems to ensure medicines that had reached their expiry date were replaced in a timely manner.

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 practice had reviewed their systems for the prescribing and monitoring of high-risk medicines.
  • Systems had been implemented to monitor and ensure medicines stocked at the practice that had reached their expiry date were replaced in a timely manner.
  • The management of medicines at the practice was supported by the Deputy Clinical Director of Pharmacy for the Royal Wolverhampton NHS Trust (RWT). The pharmacy clinical director had oversight of the RWT primary care network group of GP practices.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Procedures were in place to manage an outbreak of COVID-19 at the practice. The practice had implemented these procedures on one occasion. The practice was closed to allow deep cleaning to be carried out and patients were asked to attend their appointment at one of the other practices within the primary care group.
  • The provider used the services of an external cleaning company but were unaware of whether safe infection prevention and control practice measures were implemented and monitored during the COVID-19 pandemic.

Whilst we found no breaches of regulations, the provider should:

  • Take action to monitor and improve the completion of risk assessments undertaken by the external cleaning company used.

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

20 August 2019

During a routine inspection

We carried out an announced comprehensive inspection at Coalway Road Medical Practice on 20 August 2019 as part of our inspection programme. The service was previously inspected in May 2015 and was rated good overall. The service had a further inspection in December 2017 and was rated requires improvement overall. The reports for the inspections in May 2015 and December 2017 can be found by selecting the ‘all reports’ link for Coalway Road Medical Practice on our website at www.cqc.org.uk

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.

Following the inspection in December 2017 we found that the practice had made improvements and acted on the requirements and recommendations made in respect of safe services. We found that:

  • Staff had received up-to-date safety training appropriate to their role.
  • Safe recruitment practices were followed.
  • Systems were in place to ensure all equipment used at the practice was serviced and safe to use.
  • Health and safety risk assessments were completed and monitored.
  • Systems had been put in place to demonstrate that staff were aware and educated on the significance of NICE guidance for the assessment of patients with presumed sepsis

At this inspection we rated the practice as requires improvement for providing safe services because:

  • The practice did not have effective systems in place for the safe prescribing and monitoring of all high-risk medicines.
  • Systems for monitoring medicines stocked at the practice were not effective to ensure medicines that had reached their expiry date were replaced in a timely manner.

Following the inspection in December 2017 we found that the practice had made improvements and acted on the requirements and recommendations made in respect of having effective and well led services. At this inspection we rated the practice as good for providing effective, caring, responsive and well led services because:

  • The practice overall performance for the Quality Outcome Framework (QOF) performance score had improved. The published QOF results for 2017/2018 was 93% compared to 85% in the previous year.
  • The provider, the Royal Wolverhampton NHS Trust had ensured that all the learning and training needs of staff had been met and were up to date.
  • The practice had systems to keep clinicians up to date with current evidence-based practice.
  • We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.
  • Patients’ needs were fully assessed. This included their clinical needs and mental and physical wellbeing. We saw detailed care records supported by clear clinical pathways and protocols.
  • The practice used electronic care plan templates to plan and monitor the care of patients. We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Policies and procedures were up to date to ensure safety and provide assurances that they were operating as intended.
  • Clear and effective processes for managing risks and performance were in place.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Provide safeguarding training in line with recent guidance.
  • Develop appropriate systems for checking medicines held at the practice so that medicines identified as coming to their expiry date are replaced in a timely manner.

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