Archived: Coalpool Surgery

Updated 20 April 2017

Coalpool Surgery is located in Walsall West Midlands situated in a multipurpose modern built NHS building, providing NHS services to the local community. Coalpool Surgery is part of Phoenix Primary Care, which is a general medical service provider comprising of 12 GP practices operating in the Midlands, Bedfordshire and Herefordshire. Since the April 2016 inspection, Phoenix Primary Care merged with The Practice Group in May 2016.

Based on data available from Public Health England, the levels of depravation in the area served by Coalpool Surgery are below the national average, ranked at one out of 10, with 10 being the least deprived. Deprivation covers a broad range of issues and refers to unmet needs caused by a lack of resources of all kinds, not just financial. Based on Public Health England data the estimated ethnicity of the practice patient population are 3% mixed, 7% Asian, 3% black.

The patient list is approximately 4,150 of various ages registered and cared for at the practice. Services to patients are provided under a General Medical Services (GMS) contract with the Clinical Commissioning Group (CCG). GMS is a nationally agreed contract between general practices and the CCG for delivering primary care services to local communities.

The practice has expanded its contracted obligations to provide enhanced services to patients such as childhood vaccination and immunisation, extended hours access, facilitating timely diagnosis and support for people with dementia. An enhanced service is above the contractual requirement of the practice and is commissioned to improve the range of services available to patients.

The practice is situated on the ground floor of a multipurpose building with two other practices. There is car parking available along with facilities for cyclists and patients who display a disabled blue badge. The practice has automatic entrance doors and is accessible to patients using a wheelchair.

The practice staffing comprises of one male and two female salaried GPs, one advanced nurse practitioner, two practice nurses; one being an independent prescriber and two health care assistants. One practice manager and a team of eight staff members who cover administration, secretarial and reception duties. The practice is a training practice which facilitates GP Registrar’s (GPs in training) to gain experience and knowledge in general practice.

The practice is open between 7am to 6:30pm on Mondays and Thursdays, 8:00am to 6:30pm on Tuesday and Friday, 8:00am to 1pm on Wednesday and 9am to 12pm Saturday.

GP consulting hours are from 7am to 6:30pm on Mondays and Thursdays, 8am to 6:30pm on Tuesday and Friday, 8am to 1pm on Wednesday. Extended consulting hours are offered on Saturday from 9:30am to 10:30am for pre booked appointments; however, the telephone line is not accessible during this time. The practice has opted out of providing cover to patients in their out of hours period. During this time services are provided by NHS 111.

Updated 20 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Coalpool Surgery on 18 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Coalpool Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 14 February 2017 to confirm that the practice had carried out their plan to meet the required improvements in relation to the breaches in regulations that we identified in our previous inspection on 18 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall, the practice is now rated as good.

Our key findings were as follows:

• Since our comprehensive inspection, which took place in April 2016 the practice, systems have been implemented to monitor Quality and Outcomes Framework (QOF) performance, the uptake of childhood immunisations and national screening programmes. As a result, the practice has increased the number of under two year olds receiving a vaccination and performance is now higher than the local and national averages.

• However, when we carried out our follow up inspection we saw that national screening programs such as breast cancer remained below local and national averages.

• Previously staff we spoke with were unable to provide documentation to evidence that fire drills had been carried out. During the follow up inspection, we saw documents which showed that fire drills had taken place.

• When we first inspected the practice, some staff we spoke with were not following national guidance when acting as a chaperone. Staff we spoke with as part of the follow up inspection were able to explain how they carried out chaperoning duties. We also saw training records which showed that staff had completed training to enable them to carry out this role within national guidance.

• When we carried out the comprehensive inspection the practice identified 17 patients as carers, this was 0.41% of the practice list. Since the inspection, the practice had reviewed their carers list. Staff we spoke with during the follow up inspection explained that the practice had identified issues regarding information contained in patients care records. Staff were proactive in asking patients whether they were carers during appointments and when booking appointments. The practice had established a carers’ lead and developed a comprehensive carers’ pack. As a result, the practice had identified 65 patients as carers (4.5% of the practice list).

• During the comprehensive inspection, data provided by the practice showed that 53% of patients with a learning disability (LD) had their annual health checks in a face-to-face appointments in 2015/16. Since the comprehensive inspection the practice implemented an LD lead, all identified patients had either been sent a letter or contacted via the phone. Despite these efforts, data provided during the follow up inspection showed a 29% uptake rate in 2016/17. Staff we spoke with explained that they were aware of the slow uptake and were planning to offer dedicated Saturday clinic and were exploring ways of targeting patients during school holidays.

• Since the comprehensive inspection, the practice reviewedareas of their governance arrangements which required improvement. As a result, during the focused inspection we saw that the practice managerial team operated effective systems which enabled them to monitor training needs, staffing levels and communicate clinical audit plans and outcomes. We also saw systems in place, which supported staff to monitor prescription collection.

At our previous inspection on 18 April 2016, we rated the practice as requires improvement for providing effective and well-led services as data provided by the practice showed the uptake of medicine reviews in 2015/16 for patients diagnosed with a learning disability was 53% and the uptake of some national screening programmes were below local and national averages. At this inspection, we found that systems had been established to increase uptake; however, data provided by the practice showed uptake rates remained low. Consequently, there were areas of practice where the provider still should make further improvements.

The provider should:

• Continue exploring and implementing effective processes aimed at increasing the uptake of annual health checks in a face-to-face reviews for patients with a learning disability.

• Continue establishing effective measures to encourage patients to engage with national screening programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 20 April 2017

Updated 20 April 2017

Updated 20 April 2017

Updated 20 April 2017

Updated 20 April 2017

Updated 20 April 2017