Bilston Urban Village

Updated 14 September 2022

Bilston Urban Village Medical Centre is located in Wolverhampton. The registered address for the practice is at:

Bilston Urban Village Medical Centre

Bankfield Road

Bilston

West Midlands

WV14 0EE

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

Bilston Urban Village Medical Centre is situated within the Black Country Integrated Care Board (ICB) and provides services to approximately 12,924 patients under the terms of an Alternative Primary Medical Services (APMS) contract. APMS contracts allows providers to contract with non-NHS bodies to supply enhanced and additional primary medical services.

Information published by Public Health England shows the practice population group as in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 75.2% White, 13.9% Asian, 5.2% Black, 4.5% mixed and 1.2% other minority ethnic.

Health and Beyond Ltd. practices are organised into hubs, two practice sites are combined to form a neighbourhood hub. Each hub has a core team of health care professionals, which includes GPs, pharmacists, practice nurses, healthcare assistants and administrative support. The hubs are also supported by a range of specialist roles provided by the primary care network (PCN). This includes Healthy Aging Co-ordinator, Physicians Associate, Social Prescribing Link Worker/s, Health Coaches, Care Co-ordinators and a home visiting service.

Bilston Urban Village Medical Centre was registered with the CQC in 2019. The clinical team includes six GPs, three advanced nurse practitioners (ANP), three practice nurses, two healthcare assistants, a pharmacist and a pharmacy technician. The clinical team is supported by medical secretary’s, administration and reception staff, and a office manager. The non-clinical workforce includes a senior management team consisting of a Managing Director, a business intelligence lead and a freedom to speak up guardian.

The age distribution of the practice population shows that there is a higher working age population than the local and national averages. The number of male and female patients registered at the practice is comparable.

The practice is open between 8am to 8pm on a Monday to Friday. Extended access is currently provided at weekends from 8am to 12pm for minor illnesses. Patients are directed to the extended hours service provided by Unity, Primary Care Network. Out of hours services are accessed via the NHS 111 service.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of an appointment at one of the practice sites.

Updated 14 September 2022

We carried out an announced inspection at Bilston Urban Village Medical Centre. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Good

Well-led – Requires Improvement

This was the first visit to Bilston Urban Village Medical Centre following its registration with a new provider, Health and Beyond Ltd. in September 2019.

Why we carried out this inspection

This inspection was a comprehensive inspection to review the Health and Beyond group of services. This inspection was also planned to follow up on whistleblowing concerns we received and concerns raised by patients relating to access.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• Site visit.
• The inspections of the Health and Beyond Ltd. GP practices took place over a period of three months to provide time to follow up on the whistleblowing concerns received prior to and during the inspection process.

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 have rated this practice as Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Staff were aware of systems and processes to follow if they had any concerns.
• The partnership learned from incidents, events and complaints and ensured learning was shared among the staff team.
• Health and Beyond Ltd. had made effective use of its multiple practice sites and had made adaptations to minimise the risks to patients and staff during COVID-19.
• We found the premises were well maintained, appeared clean and tidy and had appropriate infection prevention and control arrangements in place.
• The practice also provided walk in services to increase patient access to appointments.
• Our clinical searches found patients medicines were mostly safely managed.
• The practice was supported by a pharmacy team who carried out regular audits to further support the safety of medicines prescribed.
• Advanced practitioners and GP locums were employed at the practice on a temporary contract basis to support the walk in appointment system.
• Patients received effective care and treatment that met their needs. Our review of clinical records found effective systems were in place for the follow up and monitoring of patients with long term conditions.
• A significant number of patients reported difficulties accessing care and treatment in a timely way at this practice. The partnership and management team were aware of these concerns and plans were in place to address them. It was not evident however, that there was management oversight to monitor if progress was being made to improve access for their patients.
• It was not evident that leadership arrangements could demonstrate an open culture in which staff felt engaged and enabled to raise concerns.

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

• Continue to develop centralised HR information so that it provides clear and accurate staff information for management and monitoring purposes.
• Continue to develop and improve the induction and recruitment processes and documentation.
• Provide evidence that staff vaccination and immunity for potential health care acquired infections are recorded or risk assessed for all staff.
• Continue to proactively identify carers so that they can be supported to access services available to them.
• Improve the uptake of childhood immunisations and cervical cancer screening.
• Continue to implement and monitor the action plan to improve access for patients and monitor the impact of the changes.
• Continue to implement and monitor the action planned to improve the staff working environment, communication arrangements with all staff groups and demonstrate an open culture in which staff feel engaged and enabled to raise concerns.

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