The Care Quality Commission
  • Doctor
  • GP practice

Rough Hay Surgery

Overall: Good read more about inspection ratings

44B Rough Hay Road, Rough Hay, Darlaston, West Midlands, WS10 8NQ (0121) 526 2233

Provided and run by:
Dr Uzma Ahmad

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 Rough Hay Surgery 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 Rough Hay Surgery, you can give feedback on this service.

15 November 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Rough Hay Surgery on 15 November 2022. Overall, the practice is rated as good.

We rated the key questions inspected as follows:

Safe - good

Effective - good

Well-led - good

Following our previous inspection on 25 July 2017, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Rough Hay Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

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 clinical 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 short 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 had a system in place for the actioning of significant events and incidents, however this needed strengthening to ensure all incidents were reported and shared to mitigate future risk.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Risk management processes were in place and we found assessments of risks had been completed. These included fire safety and health and safety. This ensured that risks had been considered to ensure the safety of staff and patients and to mitigate any future risks.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • There was emphasis on staff wellbeing, and this was demonstrated through discussions with staff and evidence of appraisals.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations the provider should:

  • Continue to review current system for recording incidents and significant events and implement processes to improve the sharing of learning.
  • Continue to encourage patients to attend immunisation national screening programmes such as cervical screening.

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

25 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rough Hay Surgery on 25 July 2017. 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 a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. Low scores in certain areas concerning patients’ perception of the GP had been noted by the practice and more recent survey results had shown an improvement.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns, although only three had been recorded for the previous year.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. They had begun to explore means of improving these facilities by creating new, improved premises, to better meet the needs of their patients.
  • As the principal GP was supported by non-permanent clinical staff, it was felt to be important that a more formal structure be put in place for clinical matters to be discussed.
  • There was no fire procedure displayed in the main reception area, which was acted upon straightaway.
  • The practice should continue to identify more carers on their register.
  • 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.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

  • Adopt a more thorough approach to the recording of both written and verbal complaints, in accordance with the practice policy.
  • Create a more formal structure for clinical matters to be discussed with the relevant members of the practice team.
  • Continue to identify more carers from the practice register.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice.