The Care Quality Commission
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Whitmore Reans Health Practice Also known as DrSKVij&Partners

Overall: Good read more about inspection ratings

Whitmore Reans Health Centre, Lowe Street, Whitmore Reans, Wolverhampton, West Midlands, WV6 0QL (01902) 421679

Provided and run by:
Whitmore Reans Medical Practice

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

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Whitmore Reans Health 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 Whitmore Reans Health Practice, you can give feedback on this service.

3 October 2019

During an annual regulatory review

We reviewed the information available to us about Whitmore Reans Health Practice on 3 October 2019. 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.

27 February 2018

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection at Whitmore Reans Health Practice on 10 October 2016 as part of our regulatory functions. The service was rated as requires improvement overall. The practice was rated as requires improvement for providing safe and well led services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Whitmore Reans Health Practice on our website at www.cqc.org.uk.

An announced focused inspection at Whitmore Reans Health Practice was carried out on 7 August 2017. We found improvements had been made and the overall rating for the service was good with requires improvement in providing well led services. You can read the follow up inspection report from our last comprehensive inspection, by selecting the 'all reports' link for Whitmore Reans Health Practice on our website at www.cqc.org.uk.

The registered persons had not ensured there was proper and safe management of medicines. In particular:

  • Effective systems were not embedded to demonstrate that all medicine and device safety alerts were appropriately managed.
  • Policies and procedures did not contain information that was specific to the operation of the practice.
  • Systems were not in place to monitor trends identified in significant events.

This inspection was an announced focused inspection carried out on 27 February 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 7 August 2017.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • Effective systems were in place to demonstrate that all medicine safety and device alerts were appropriately managed.
  • Policies and procedures had been reviewed to ensure that they contained information that was specific to the operation of the practice. It was not evident that clinical staff were involved in the reviews to ensure the policies and procedures reflected current clinical guidance where appropriate.
  • Systems had been put in place to monitor and act on trends identified in significant events.

The areas where the provider should make improvements:

  • Continue to update practice policies and procedures with the support of clinical staff where appropriate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Whitmore Reans Health practice on 10 October 2016. After the comprehensive inspection, the practice was rated as requires improvement for providing safe and well-led services.

We issued a requirement notice in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.
  • Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Good Governance.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Whitmore Reans Health Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 10 October 2016. This report covers our findings in relation to those requirements.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Arrangements were in place to demonstrate learning from significant events and ongoing monitoring ensured that improvements made were appropriate.
  • The practice had reviewed and implemented systems to minimise risks to patients. However further improvement was needed to ensure that appropriate arrangements were in place for ensuring medicine safety alerts are received and acted on in a timely way.
  • The practice had reviewed its systems and procedures to ensure the safe management of high risk medicines and introduced ongoing monitoring to check improvements were maintained.
  • A programme of clinical audits had been identified and arrangements for completing clinical audit cycles to support timely and appropriate improvements in the quality of patient care were in place.
  • A system for managing patients’ discharge letters and medicine changes was in place.
  • Arrangements for improving the uptake of childhood annual immunisations had been reviewed. Procedures had been implemented to ensure children who did not attend appointments were actively followed up and referred to the appropriate professionals.
  • Procedures to ensure the confidentiality of patient information had been reviewed.
  • Records of all home visits carried out were maintained.
  • Staff had updated the policies and procedures for the practice. These were updated but were not all written to ensure they were specific to the operation of the practice.

There were areas of practice where the provider must make improvements:

Ensure care and treatment is provided in a safe way to patients in particular:

  • Ensure that effective systems are embedded to demonstrate that all medicine safety and device alerts are appropriately managed.

There were areas of practice where the provider should make improvements:

  • Ensure that policies and procedures contain information that is specific to the operation of the practice.
  • Ensure systems are in place to monitor trends identified in significant events.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Whitmore Reans Health Practice on 5 December 2014. The practice was rated as requires improvement overall. The full comprehensive report on the December 2014 inspection by selecting the 'all reports' link for Whitmore Reans Health Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 10 October 2016. We found that the practice had met the requirements of the requirement notice issued and addressed the recommendations made at the December 2014 inspection. However other issues identified at this inspection has meant that the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to act on significant events but formal arrangements were not in place for the ongoing monitoring of any changes made and ensuring improvements are appropriate.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure they meet people’s needs.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Most risks were well managed, although action was needed in the areas of medicines management.
  • Patients said they were treated with compassion, dignity and respect and the majority of feedback from patients about their care was positive.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a result of feedback from patients and from the patient participation group.
  • The practice facilities were well equipped and maintained to treat and meet patients’ needs.
  • Clinical audits were carried out and demonstrated improvement. However there were long periods between audit cycles
  • The practice had visible clinical and managerial leadership and governance arrangements.

However there were areas of practice where the provider must make improvements:

  • Implement a recorded system to receive and act on alerts that may affect patients’ safety.
  • Ensure systems are put in place for the proper and safe management of medicines.
  • Ensure arrangements are in place to monitor and improve the quality of the service.

There were areas of practice where the provider should make improvements:

  • Introduce formal arrangements for the ongoing monitoring of significant events to prevent further occurrences and ensure that improvements made are appropriate.
  • Carry out practice specific health and safety assessments.
  • Review the arrangements for shared care agreements so that the practice can gain access to patient test results before issuing a repeat prescription.
  • Introduce a process for regularly reviewing Patient Group Directions to ensure that they meet legislative requirements.
  • Review the arrangements for completing clinical audit cycles to support timely and appropriate improvements in the quality of patient care.
  • Review the system for managing patients’ discharge letters and medicine changes.
  • Improve the uptake of childhood annual immunisations.
  • Ensure that confidentiality of patient information is maintained at all times in line with Data Protection Regulations.
  • Ensure that a record of all home visits carried out is maintained.
  • Ensure that policies and procedures for the management of medicines are updated to reflect current practices.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

The provider, Whitmore Reans Medical Practice have practices at three locations in Wolverhampton: Whitmore Reans Health Practice; Ednam Road Surgery and Pendeford Health Centre. Although all three are currently registered separately with the Care Quality Commission (CQC), they share one overall registered patient list. Ednam Road Surgery and Pendeford Health Centre operate as branch surgeries, with patients able to visit any of the three practices in order to access primary medical services.This inspection focused on Whitmore Reans Health Centre which was the main location.

We inspected Whitmore Reans Health Practice, Whitmore Reans Health Centre,Lowe Street, Wolverhampton, WV6 0QL on 5 December 2014 as part of a comprehensive inspection. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective and well-led services. The areas for improvements that led to these ratings also applied to all of the six population groups that we inspect. These are, people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health. We rated the practice good for providing a caring and responsive service.

Our key findings were as follows:

  • The systems in place to ensure patients received a safe service were not robust.
  • There were examples of evidence based practice which was referenced in patients care and treatment to ensure positive outcomes were achieved. However, the arrangements in place to identify, review and monitor patients with some long term conditions were not always effective.
  • Patients were complimentary about the staff at the practice and said they were caring, listened and gave them sufficient time to discuss their concerns.
  • The practice was responsive to the needs of the practice population. There were services aimed at specific patient groups and the practice pro-actively engaged with patients in the local community to promote good health.
  • We identified during the inspection areas for improvements such as recruitment procedures and effective systems for reviewing patients with long term conditions. This demonstrated that governance arrangements at the practice should be improved. The leadership structure in place were not clearly defined and some of the staff members were at times uncertain about their roles and responsibilities.

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

Importantly, the provider must

  • Operate effective recruitment procedures and ensure that the information required under current legislation is available in respect of all staff employed to work at the practice.

In addition the provider should:

  • Ensure significant events are documented in detail to show learning and reflection.
  • Review arrangements to assess, manage and monitor the needs of patients with a diagnosis of dementia and those receiving end of life care. The practice should ensure appropriate follow up is provided to patients receiving NHS health checks carried out by other services and those recently discharged from hospital.
  • Ensure that the needs of patients who may have difficulty accessing the service are taken into consideration.
  • Develop a robust process for the monitoring of training in order to provide assurance that staff have the knowledge and skills they need to deliver care safely and effectively.
  • Review the governance arrangements at the practice to ensure clear leadership structures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice