Rough Hay Surgery

Updated 19 December 2022

Rough Hay Surgery is located in Darlaston at:

44B Rough Hay Road

Darlaston,

Walsall,

WS10 8NQ

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

The practice is situated within Black Country and West Birmingham Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 3,800. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices called West 2 primary care network.

Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one 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 78% White, 14.9% Asian, 3.4% Mixed, 3.1% Black and 0.6% Other. The age distribution of the practice population closely mirrors the local and national averages.

There is a principal GP who is supported by two long term locum GPs. The practice has a nurse prescriber and has recently recruited a practice nurse. A health care assistant supports the clinical team. The GPs are supported at the practice by a team of reception/administration staff. The practice manager provides managerial oversight. The practice is a GP training practice for GP registrars.

The practice is open between 8am to 6.30pm Monday, 7.30am to 6.30pm Tuesday, 7.50am to 6.30pm Wednesday, 8am to 1pm Thursday, 7.30am to 7pm Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. On Thursday afternoon the phone lines are covered by an alternative provider contracted by the practice. Extended access is provided locally through the primary care network, where late evening and weekend appointments are available. Out of hours services are provided by NHS111.

Updated 19 December 2022

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