The Care Quality Commission
  • Doctor
  • GP practice

Pedmore Medical Practice

Overall: Good read more about inspection ratings

22 Pedmore Road, Lye, Stourbridge, West Midlands, DY9 8DJ (01384) 422591

Provided and run by:
Pedmore Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Pedmore Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Pedmore Medical Practice, you can give feedback on this service.

28 February 2020

During an annual regulatory review

We reviewed the information available to us about Pedmore Medical Practice on 28 February 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

12 January 2018

During a routine inspection

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

30 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pedmore Medical Practice on 30 November 2016. This inspection was carried out further to our previous comprehensive inspection at Pedmore Medical Practice which took place on 22 October 2015.

As a result of our previous comprehensive inspection, breaches of legal requirements were found and the practice was rated as requires improvement overall with an Inadequate rating for providing safe services. This was because we identified some areas where the provider must make improvements and an area where the provider should improve. The practice completed an action plan to outline what they would do to meet legal requirements in relation Regulation 12: safe care and treatment HSCA (RA) Regulations 2014. This inspection was conducted to see if improvements had been made in line with the practices action plan.

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.

Overall the practice is rated as requires improvement. Our key findings across all the areas we inspected were as follows:

  • There were effective systems in place for reporting incidents, as well as comments and complaints received from patients.
  • During our inspection we saw that staff were friendly and helpful and treated patients with kindness and respect. Patients we spoke with during our inspection told us they were satisfied with the care and treatment they received.
  • We identified that in some areas patients were not up to date with medication reviews. This was mostly across areas such as dementia, mental health and learning disability care. Staff assured us that they were working on a recall system in order to ensure patients were up to date with reviews and were also developing care plans where needed.
  • The practice was based in a three story building with purpose built consulting and treatment rooms on the ground and first floor of the building. We noticed a ramp was in place to allow for wheelchair and pushchair users to enter and exit the practice however there was no lift in place to support people with mobility difficulties. The practice advised that staff would move between consulting rooms to suit patient needs and that reception staff were advised to book appointments in to suit patient preferences.
  • Since our previous inspection in October 2015 the practice had completed a equality assessment which was supported by a practice protocol. Records indicated that the practice had looked in to installing a stair lift previously however this was unable to take place due to major building changes that would have been required for the work.
  • During our most recent inspection we noted improvement with regards to risk management. However, we noted some areas where governance arrangements were not as effective. This included gaps in record keeping of fridge temperatures, cleaning of medical equipment and gaps in systems for monitoring emergency medicines and prescription stationery. We also noted that although risk management had improved, the practice had not formally assessed risks associated with portable heaters which were situated in patient and staff areas.
  • We saw that policies and documented protocols were well organised and available as hard copies and also on the practices intranet. Although the practice had a protocol for repeat prescribing, we received inconsistent information from staff when discussing the process for prescribing and monitoring certain high risk medicines.
  • Members of the management team explained that the practice no longer had a patient participation group (PPG). Staff we spoke with advised that they would like to get a PPG back up and running however we did not receive evidence or formal plans in place to support this.
  • We noted that all staff spoke positively about working at the practice and that they came across as part of a close, committed and very dedicated team. Staff we spoke with demonstrated a commitment to providing a high quality service to patients.

The areas where the provider must make improvements are:

  • Continue to work through recall systems and ensure that care plans are continually completed in line with patients needs. Ensure that medication reviews are always part of patient’s care and treatment assessments as required.
  • Improve governance arrangements and ensure adequate record keeping is in place to reflect systems for monitoring the cold chain, cleaning of medical equipment, checking of emergency medicines and assessing risks associated with safety of equipment; such as portable heaters.

The areas where the provider should make improvements are:

  • Continue to identify carers in order to provide further support where needed.
  • Maximise the functionality of the computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.
  • Implement and engage with a patient participation group (PPG) to ensure consistent feedback from patients.
  • Ensure a process is in place for the tracking of prescription stationery.
  • Ensure that protocols are effectively embedded to support safe and effective systems for prescribing high risk medicines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pedmore Medical Practice on 22 October 2015. Overall the practice is rated as requires improvement.

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

  • Formal risk assessments were not in place to monitor health and safety of the premises to ensure that the premesis used by the practice were safe to use for the intended purpose and used in a safe way.
  • The practice had not assessed risks associated with infection control. Therefore, these risks were not being managed well enough to ensure staff and patients were kept safe.
  • Patients said they found it easy to make an appointment, with urgent appointments available the same day.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patient care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • We found that risk assessments were not in place in the absence of disclosure and barring checks (DBS checks) for staff that chaperoned.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

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

The areas where the provider must make improvements are:

  • Assess and manage risks associated with health and safety of the premises and fire risk.
  • Assess and manager risks associated with infection control including control of substances hazardous to health and legionella.
  • Ensure formal risk assessments are completed to assess the risk of not having disclosure and barring checks (DBS) for staff that chaperone.

In addition, the provider should:

  • Implement a system of audit in relation to infection control to ensure appropriate standards are maintained.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected within six months after the report is published. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice