The Care Quality Commission
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  • GP practice

Poplars Medical Practice

Overall: Good read more about inspection ratings

122 Third Avenue, Low Hill, Wolverhampton, West Midlands, WV10 9PG (01902) 731195

Provided and run by:
Poplars Medical Practice Limited

All Inspections

25 October 2022

During a routine inspection

We carried out an announced comprehensive at Poplars Medical Practice on 25 October 2022. Overall, the practice is rated as good.

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

Previous inspections carried out at Poplars Medical Practice included an announced comprehensive inspection on 28 December 2014 as part of our inspection programme. The practice was rated inadequate for providing safe, effective and well led services, requires improvement for providing responsive services and good for the provision of caring services. The practice was rated inadequate overall and placed in special measures.

We carried out an announced focused inspection out on 18 November 2015 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations we identified at our previous inspection on 28 December 2014. At the focused inspection on 18 November 2015 we found that the practice had resolved the concerns raised and met the requirement notices issued. However, a new issue was identified and the practice was rated requires improvement for providing safe services with an overall rating of good.

A focused inspection carried out on 28 January 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breach in regulations we identified at our previous inspection on 18 November 2015. At the inspection we found that the practice had met the requirement notice and was rated as good for providing safe services.

An inspection was undertaken on the 16 March 2021. This was a focused inspection, carried out in response to concerns received by the Care Quality Commission (CQC). The inspection was not rated however, requirement notices were issued relating to safe care and treatment and Good Governance. At this inspection, 25 October 2022 we found that all the requirement notices had been met.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Poplars Medical Practice 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 carried out in March 2021.

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 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:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff demonstrated awareness of actions required if they suspected safeguarding concerns.
  • Staff files were not all organised so that relevant documents were readily and easily accessible in one place.
  • We found that the immunisation status of all staff was not consistently available to demonstrate any immunisation that was incomplete.
  • The practice had a system for recording and disseminating actions carried out as a result of significant events to support learning and improvement.
  • The practice had taken appropriate action to support and protect patients identified as at risk from harm.
  • Patients received effective care and treatment that met their needs.
  • Although patients medical reviews were mostly comprehensively and clearly documented to provide details of the review and its outcome we noted that there were some gaps.
  • There was a below average uptake by patients of preventative treatments in particular, cervical screening and some age groups for childhood immunisations
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The results of the National GP Patients survey identified that patients had a positive experience of the practice and felt there was access to timely care and treatment.
  • The practice leaders had management oversight of staff qualifications and training.
  • Staff were clear and knowledgeable about their roles and responsibilities.
  • Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
  • The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centred care.

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

  • Continue to improve the organisation and accessibility of staff recruitment records.
  • Provide evidence that staff vaccination and immunity for potential health care acquired infections are recorded or risk assessed for all staff.
  • Provide evidence that staff who are qualified to administer medicines under the authorisation of patient group directions have signed current and updated authorisations before administering the medicines.
  • Review the risk assessments in place for emergency medicines not routinely held at the practice so that they contain sufficient information to demonstrate how the level of any risk will be mitigated.
  • Implement systems for the ongoing monitoring and review of the completeness of documentation and updating of patient records following clinical and medicines reviews.
  • Introduce processes for the ongoing review and follow up of safety alerts to demonstrate that any changes or action taken in response to the alert is maintained.
  • Improve the uptake of childhood immunisations and cervical cancer screening.
  • Continue to proactively identify carers so that they can be supported to access services available to them.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

16 March 2021

During an inspection looking at part of the service

We carried out a remote inspection review at Poplars Medical Practice on 11 March 2021 with a remote video interview on 16 March 2021 in response to concerns received by the Care Quality Commission (CQC).

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. We obtained the information in it without visiting the provider.

We previously carried out an announced comprehensive inspection at Poplars Medical Practice on 28 December 2014 as part of our inspection programme. The practice was rated inadequate for providing safe, effective and well led services, requires improvement for providing responsive services and good for the provision of caring services. The practice was rated inadequate overall and placed in special measures.

We carried out an announced focused inspection out on 18 November 2015 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations we identified at our previous inspection on 28 December 2014. At the focused inspection on 18 November 2015 we found that the practice had resolved the concerns raised and met the requirement notices issued. However, a new issue was identified at this inspection and the practice was rated requires improvement for providing safe services with an overall rating of good.

A further focussed inspection was carried out on 28 January 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breach in regulations we identified at our previous inspection on 14 November 2015. At the inspection we found that the practice had met the requirement notice and was rated as good for providing safe services.

You can read the reports from our last inspections by selecting the ‘all reports’ link for Poplars 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 found that:

  • Contemporaneous record keeping was not continuously completed in patient medical records to demonstrate that a clinical assessment, diagnosis and treatment plan was completed.
  • The provider had not ensured that appropriate and up to date reviews and monitoring information was always recorded in the clinical records of patients prescribed high risk medicines.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review and audit information recorded in patient medical records to ensure consistency in the standard of documentation.
  • Review and audit information recorded for patients receiving high risk medicines to demonstrate the care provided is consistent and the outcome of test results are recorded in patients’ medical records.
  • Seek the views of patients to gain feedback on the responsiveness of the service and promote the delivery of high-quality, person-centre care.
  • Maintain detailed minutes of meetings to demonstrate that meetings are established, effective and consider the views of staff.
  • Review the management oversight system for patients referred to services such as counselling.

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 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Poplars Medical Practice on 18 November 2015. A total of one breach of legal requirement was found. After the focussed inspection, although the practice was rated good overall, it was rated as requires improvement for providing safe services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Poplars Medical Practice on our website at www.cqc.org.uk.

Following the inspection in November 2015 we issued requirement notices in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.

This inspection was a desktop focused inspection carried out on 20 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified at our previous inspection on 18 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients and staff were assessed and health and safety risk audit records improved to ensure sufficient information was recorded to demonstrate the level of risk, action to be taken and by whom.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. The female locum GP who was working at the practice at the time of the  inspection in November 2015 had left. To address this the advanced nurse practitioner had the skills to meet some of the clinical needs of female patients registered at the practice. Female patients were made aware of this and potential female patients were made aware that the practice did not have a female GP. This ensured that they could make an informed decision as to whether they wanted to register as a patient at the practice.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The appointment system had been reviewed and changes made to improve patients experiences. Changes were monitored to ensure the length of time patients had to wait to be seen at their appointment showed ongoing improvement.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Clinical audits had been carried out to monitor the quality of service provided to patients.
  • There was a clear leadership structure and staff felt supported by the management.
  • The practice proactively sought feedback from patients. The practice worked effectively with the patient participation group to encourage active involvement in the improvement of the practice. The group was discussing the possibility of a virtual group.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

At this inspection we found that the practice had acted on the concerns identified at the inspection November 2015 and as a consequence ratings for the practice has been updated to reflect our most recent findings. The practice is now rated as good for providing safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Poplars Medical Practice on Wednesday 18 November 2015.

This inspection was in follow up to our previous comprehensive inspection at the practice on 8 December 2014 where breaches of legal requirements were found. The overall rating of the practice following the 2014 inspection was inadequate and the practice was placed into special measures for a period of six months. After the inspection in December 2014 the practice wrote to us to say what they would do to meet legal requirements in relation to providing safe, effective, responsive and well-led services.

At our inspection on 18 November 2015 we found that the practice had improved. The five requirement notices we issued following our previous inspection related to the delivery of safe, effective and well-led care and all had been met. The ratings for the practice have been updated to reflect our most recent findings. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients and staff were assessed; however completed health and safety risk audit records did not contain sufficient information to demonstrate the level of risk, action to be taken and by whom.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Disclosure and barring checks (DBS) had been completed for all staff.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients were concerned about the length of time they had to wait to be seen at their appointment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Clinical audits had been carried out to monitor the quality of service provided to patients.
  • There was a clear leadership structure and staff felt supported by management. Although further improvement was still needed the practice had sought feedback from patients and had a patient participation group.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Provide a suitable means to provide high-flow oxygen therapy to patients in an emergency situation.

The areas where the provider should:

  • Improve record keeping of significant events to evidence investigation, discussion and learning from the events.
  • Complete the action points contained in the practice Legionella risk assessment.
  • Review the method of handling blank prescriptions within the practice to reflect national recognised guidance as detailed in NHS Protect
  • Consider carrying out a review of the appointments system.
  • Consider how the patient participation group can be encouraged and supported to be more involved in the continuous improvement of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Poplars Medical Practice on 8 December 2014. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, effective and well-led services. It required improvement for providing responsive services. It was good for providing a caring service. It was also inadequate for providing services for the six population groups.

Our key findings across all the areas we inspected were as follows:

  • The practice did not have robust governance arrangements to effectively manage risks to protect patients from harm and improve the quality of services provided.
  • Data showed patient outcomes were average or below average for the locality. Although some audits had been carried out, we saw little evidence that audits were driving improvement in performance and patient outcomes.
  • National data available indicated patients were very satisfied with the service received and were treated with dignity and respect. However, negative feedback had been received in response to recent staffing changes at the practice.
  • Appropriate supervision arrangements were not in place for clinical staff working independently.
  • Information about how to complain was available and easy to understand but evidence seen did not provide assurance that complaints were being well managed.
  • Urgent appointments were usually available on the day they were requested. Patients reported that they were satisfied with access to appointments.
  • Systems for obtaining and acting on feedback from staff or patients were not well embedded.

The areas where the provider must make improvements are:

  • Ensure effective systems are in place for the management of risks to patients and others against inappropriate or unsafe care. This should include the management of unforeseen events, the premises, staffing and recruitment.
  • Ensure robust governance arrangements are in place to assess and monitor the quality of services provided. Ensure audits complete their full audit cycle in order to demonstrate improvements made to the practice.
  • Establish robust recruitment processes to ensure only suitable staff are employed. Roles should be risk assessed in the absence of criminal record checks to determine whether they are required.
  • Ensure that staff have clearly defined roles and responsibilities with appropriate support and supervision to ensure they are working within their competencies. Ensure staff are supported by robust policies and guidance to carry out their roles safely and effectively.
  • Ensure consent for treatment is appropriately documented to demonstrate that risks, benefits and complications associated with the procedure have been explained and understood by the patient.
  • Establish robust systems for the management and handling of complaints.

In addition the provider should:

  • Ensure staff are supported by robust policies and guidance to carry out their roles safely and effectively.
  • Ensure information is routinely shared with other services such as the out of hours provider to ensure patients receive good continuity of care.
  • Develop a systematic approach to identifying and targeting health promotion and preventative care services for patients who would benefit from them.
  • Ensure staff are aware of systems to support patients who may have difficulty accessing the service (such as language and other barriers).
  • Develop robust systems to ensure the patient voice is heard and taken into account in developing and delivering services.

On the basis of the ratings given to this practice at this inspection, (and the concerns identified at our previous inspection), I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice