The Care Quality Commission
  • Doctor
  • GP practice

Quincy Rise Surgery

Overall: Good read more about inspection ratings

30 Sandringham Way, Brierley Hill, West Midlands, DY5 3JR (01384) 422698

Provided and run by:
Dr Mubashir 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 Quincy Rise 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 Quincy Rise Surgery, you can give feedback on this service.

11 May 2021

During a routine inspection

We carried out an unannounced focused inspection at Quincy Rise Surgery on 21 October 2020 and found breaches against Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was an unrated inspection however, warning notices were issued against Regulation 12(1) Safe care and treatment, Regulation 17(1) Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following our inspection in October 2020, the practice wrote to us with an action plan, outlining how they would make the necessary improvements to comply with the regulations. The provider submitted additional information and evidence to us electronically to demonstrate improvements had been made to comply with the regulations.

We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of follow-up inspection was necessary and proportionate. As a result, we carried out a remote assurance review of this information, which included a virtual meeting with the provider, on 2 February 2021 to confirm whether the practice had taken sufficient action to comply with the warning notices. We found the provider had made improvements and was compliant with the Warning Notices issued. The practice was not rated as a result of this review.

We carried out an announced inspection at Quincy Rise Surgery on 10 and 11 May 2021 to assure us that the practice was compliant with the regulations. Overall, the practice is rated as Good overall.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

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

Why we carried out this inspection

This was a comprehensive inspection to follow up concerns from our inspection on 21 October 2020 which led to breaches against Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 inspection 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
  • 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 have rated this practice as Good overall and good for all population groups with the exception of people experiencing poor mental health (including those with dementia) which we rated as requires improvement.

We found that:

  • Systems and processes to keep patients safe had been improved. The practice had acted to address areas of identified non-compliance.
  • Staff had completed the required training for their roles. Systems were in place to manage and monitor training for staff in the practice.
  • Disclosure and Barring Service (DBS) checks had been completed for all staff and recruitment checks were in accordance with the regulations.
  • There was a lead for infection prevention and control. A recent audit had been completed and all staff had completed training.
  • Processes to assess, monitor and manage governance and safety systems had been improved.
  • The practice had undertaken a review of medicines held for dealing with medical emergencies. Risk assessments had been completed for those medicines not held on-site.
  • The practice had developed systems to manage and monitor emergency equipment held within the practice and had carried out regular checks of that equipment.
  • There was a formalised approach to staff meetings for practice improvements.
  • Staffing had been strengthened for clinical and non-clinical staff with oversight and review as part of the leadership management.
  • Clear processes had been established and set out as part of managing risk, issues and performance.

We have rated the population group of people experiencing poor mental health (including those with dementia) as Requires Improvement because:

  • Mental health indicators were below local and national averages and action taken had not yet demonstrated improved outcomes.

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

  • Continue to review immunisation needs against possible infections for staff in non-clinical patient facing roles.
  • Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
  • Continue work to identify and support carers registered at the practice.
  • Continue with steps to engage with a patient participation group.

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

02 February 2021

During an inspection looking at part of the service

We carried out an unannounced focused inspection at Quincy Rise Surgery on 21 October 2020 and found breaches against Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Warning notices were issued against Regulation 12(1) Safe care and treatment, Regulation 17(1) Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following our inspection in October 2020, the practice wrote to us with an action plan, outlining how they would make the necessary improvements to comply with the regulations. The provider submitted additional information and evidence to us electronically to demonstrate improvements had been made to comply with the regulations.

We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of follow-up inspection was necessary and proportionate. As a result, we carried out a remote assurance review of this information, which included a virtual meeting with the provider, on 2 February 2021 to confirm whether the practice had taken sufficient action to comply with the warning notices. This report only covers our findings in relation to our review of that information. The practice was not rated as a result of this review.

We found the provider had made improvements and was compliant with the Warning Notices issued at our last inspection.

Our key findings were:

  • Systems and processes to keep patients safe had been improved. The practice had acted to address areas of identified non-compliance.
  • Staff had completed the required training for their roles. Systems were in place to manage and monitor training for staff in the practice.
  • Disclosure and Barring Service (DBS) checks had been completed for all staff and recruitment checks were in accordance with the regulations.
  • There was a lead for infection prevention and control. A recent audit had been completed and all staff had completed training.
  • Processes to assess, monitor and manage governance and safety systems had been improved.
  • The practice had undertaken a review of medicines held for dealing with medical emergencies. Risk assessments had been completed for those medicines not held on-site.
  • The practice had developed systems to manage and monitor emergency equipment held within the practice and had carried out regular checks of that equipment.
  • There was a formalised approach to staff meetings for practice improvements.
  • Staffing had been strengthened for clinical and non-clinical staff with oversight and review as part of the leadership management.
  • Clear processes had been established and set out as part of managing risk, issues and performance.

Details of our findings and the evidence supporting our decisions are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

21 October 2020

During an inspection looking at part of the service

We carried out an unannounced focused inspection at Quincy Rise Surgery on 21 October 2020 in response to concerning information received. This included concerns regarding the staffing, health and safety, culture, and leadership oversight. There was also concerns regarding the safety and infection control measures in place during the COVID-19 pandemic that were not compliant with guidance.

The practice was last inspected in January 2017 and was rated Good overall. You can read the full report by selecting the ‘all reports’ link for Quincy Rise Surgery on our website at: www.cqc.org.uk

We were mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID -19 pandemic when considering what type of inspection was necessary and proportionate. At this inspection we followed up on areas of concern using our focused inspection methodology.

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.

This was an unrated focused inspection.

We found that:

  • The practice did not have clear systems and processes to keep patients safe.
  • There were gaps in staff training and not all staff had received the appropriate level of safeguarding training, nor fire safety or infection prevention and control training.
  • Disclosure and barring checks (DBS) had not been carried out for all staff and there were no risk assessments in place to mitigate risks for staff who chaperoned.
  • There were gaps in systems to assess, monitor and manage risks to patient safety, including recruitment, infection prevention and control and safety checks for the premises.
  • There was no oversight of infection prevention and control in the practice.
  • There was no effective and formalised approach to managing staff absences.
  • There was a lack of systems in place to monitor medicines and equipment in the practice. We found a number of emergency medicines were not being held by the practice and there was no risk assessment in place to demonstrate the rationale for this. There was no system in place for monitoring medical equipment to ensure they were in good working order.
  • There was no evidence of staff meetings or learning from significant events, complaints or patient safety that would lead to practice improvements.
  • The practice did not have an effective system in place to monitor training. Staff training was incomplete or had lapsed and therefore, we could not be assured that staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was a lack of leadership oversight and the absence of comprehensive systems and processes to monitor the quality and effectiveness of the service and the care provided.
  • The practice had not implemented a clear and effective process for managing risks, issues and performance.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

Following this inspection enforcement action was taken against this provider for regulation 12, safe care and treatment and regulation 17 good governance. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted , and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

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

2 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Quincy Rise Surgery was previously registered with the Care Quality Commission (CQC) as a partnership provider. A change of provider took place in January 2017 when the practice re-registered as a single handed GP. The previous GP partner had left in July 2016. We first inspected Quincy Rise Surgery across two dates on 9 March and 4 April 2016.

As a result of our inspection visits, the practice was placed in special measures and was rated as inadequate overall. This was because we identified regulatory breaches in relation to regulation 12 for providing safe care and treatment and regulation 17 due to inadequate governance arrangements. As breaches of legal requirements were found we issued two warning notices and a requirement notice. We carried out an announced focused inspection at Quincy Rise Surgery on 18 July 2016 to focus on the areas identified in the waning notices. Although we saw that improvements had been made, the practice did not fully meet the requirements of the warning notice for Regulation 12: safe care and treatment HSCA (RA) Regulations 2014. We carried out an announced comprehensive inspection at Quincy Rise Surgery on 23 November 2016 to see if improvements had been made in line with the special measures period of six months following publication of the final report. Overall the practice was rated as good and was taken out of special measures. However we rated the practice as requires improvement for well led having found that governance systems and processes were not always effectively operated to support a well led and open cultured team. The reports for the inspection carried out on 9 March and 4 April 2016, July 2016 and November 2016 can be found by selecting the ‘all reports’ link for Quincy Rise Surgery on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Quincy Rise Surgery on 2 October 2017, the first inspection under the new legal entity. The practice is rated as good overall.

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

  • There was an open and transparent approach to safety and an effective 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 and had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • The practice maintained appropriate standards of cleanliness and hygiene.
  • Appropriate recruitment checks had been undertaken prior to employment although satisfactory information about any physical or mental health conditions relevant to a person’s ability to carry out their role had not been obtained for all staff.
  • Most results from the national GP patient survey published in July 2017 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. Where scores were below average the practice was able to demonstrate an awareness and mitigation.
  • Information about services and how to complain was available and the practice proactively acted on complaints posted on the national website, NHS Choices. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients found it easy to make an appointment 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.
  • There was a clear leadership structure and staff felt supported by the management team.
  • 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:

  • Ensure health and safety arrangements minimise the risks to patients, staff and visitors.
  • Prior to employment, obtain satisfactory information about any physical or mental health conditions relevant to a person’s ability to carry out their role.
  • Increase awareness of practice performance against the new Dudley Clinical Commissioning Group Provider Outcome Framework.
  • Explore ways in which to increase the number of patients on the carers’ register and identify those patients who also acted as carers on the clinical system.
  • Continue to monitor and further improve the patient satisfaction scores.
  • Include information on how to make a complaint on the practice website.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice