Pedmore Medical Practice

Updated 8 March 2018

Pedmore Medical Practice is located in the Stourbridge area of Dudley and delivers regulated activities from the Pedmore Road Practice only.

The practice is registered with the Care Quality Commission (CQC) as a partnership provider and holds a General Medical Services (GMS) contract with NHS England and provides a number of enhanced services to include minor surgery. A GMS contract is a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract. The practice is part of the NHS Dudley Clinical Commissioning Group (CCG).

The practice treats patients of all ages and provides a range of medical services. There are currently 3,962 registered patients at the practice. The practice local area is one of overall average deprivation when compared with the local and national averages but there are pockets of highly deprived areas. The practice has a higher percentage of patients aged 65 and over (26%) compared to the national average (17%) which could mean an increased demand for GP services. The practice has 56% of patients with a long-standing health condition compared to the CCG average of 56% and the national average of 53%,

The practice is situated in a privately owned ex-residential premises owned and maintained by a retired partner, with a formal lease agreement in place. The practice is owned and managed by a team of three GP partners who are supported by a salaried GP, a long-term locum GP, two practice nurses, a practice manager and an administration team. Opening hours are between 8am and 6.30pm Monday to Friday. The appointment system allowed patients to walk in and be seen in addition to offering pre-bookable appointments. Extended hours appointments are available on Monday and Wednesday evenings from 6.30pm to 7.15pm for patients who would otherwise find it difficult to attend the practice during the day due to work or unforeseen circumstances. These extended hours are also available to unregistered patients as part of a CCG improved access scheme.

Additional information about the practice is available on their website: www.pedmoremedicalpractice.co.uk

Updated 8 March 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. We previously inspected the service on 30 November 2016. As a result of our previous comprehensive inspection, we rated the service as requires improvement overall, with the safe, effective and well-led key questions rated as requires improvement. The practice was rated as good in the caring and responsive key questions. We found a breach of the legal requirements and as a result we issued a requirement notice in relation to:

There were gaps found in governance arrangements; care plans had not always been completed in line with patient needs, and is some areas, patient medication reviews were overdue. Systems to monitor cleaning and emergency equipment and medicines checks also needed strengthening.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Pedmore Medical Practice on our website at www.cqc.org.uk

We carried out an announced comprehensive inspection at Pedmore Medical Practice on 12 January 2018 to monitor that the necessary improvements had been made.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

At this inspection we found:

• The practice had systems, processes and practices in place to protect people from potential abuse. Staff were aware of how to raise a safeguarding concern and had access to internal leads and contacts for external safeguarding agencies. Staff had received up-to-date safeguarding training relevant to their role.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice had improved arrangements for managing infection prevention and control. An external audit had been completed since the last inspection and the practice had achieved a 96% overall score.
• There were systems in place for identifying, assessing and mitigating most risks to the health and safety of patients and staff. However, not all environmental risks to patients and staff had been formally assessed.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice kept a training matrix that included planned dates for those staff who had not received essential training.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found it easy to make an appointment by telephone and told us appointments with GPs were readily available when needed.
• The practice had suitable facilities and was well equipped and maintained to treat patients and meet their needs.
• The practice were aware and monitored patient feedback and were proactively trying to reinvigorate the patient participation group.
• Governance arrangements for managing patient care had significantly improved. The practice closely monitored the management of patients with long-term conditions and performance data showed that the practice were at or above average when compared with other local practices.
• The practice had implemented effective systems of record keeping to monitor the areas identified at the previous inspection as in need of improvement.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to improve the health and safety arrangements.
• Review the recruitment process to ensure a physical and mental health assessment on all staff employed to ensure suitability to carry out their role.
• Update safeguarding policies to include the most recent definitions.
• Complete the staff training programme to provide essential training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 8 March 2018

Updated 8 March 2018

Updated 8 March 2018

Updated 8 March 2018

Updated 8 March 2018

Updated 8 March 2018