The Care Quality Commission
  • Doctor
  • GP practice

Fordhouses Medical Centre

Overall: Good read more about inspection ratings

68 Marsh Lane, Wolverhampton, West Midlands, WV10 6RU (01902) 398111

Provided and run by:
Dr Rohini Kharwadkar

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Fordhouses Medical Centre 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 Fordhouses Medical Centre, you can give feedback on this service.

3 October 2019

During an annual regulatory review

We reviewed the information available to us about Fordhouses Medical Centre 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.

10 April 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 Fordhouses Medical Centre on 13 July 2016. A total of two breaches of legal requirements were found. After the comprehensive inspection, the practice was rated as requires improvement.

We issued requirement notices in relation to:

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

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Fordhouses Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 April 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 13 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. There was a lack of detail in records to confirm discussions that had taken place.
  • Risks to patients were assessed and well managed. The practice had improved its procedures to ensure appropriate recruitment checks had been completed, DBS checks had been carried out.
  • Staff training records had been updated and staff appraisals, competency checks and supervision completed.
  • Procedures had been reviewed and systems introduced to ensure the safe management of medicine safety alerts.
  • A full legionella risk assessment had been completed and any recommendations made acted on.
  • Complaint leaflets were appropriately placed to ensure patients had easy access.
  • The practice had looked at ways to pro-actively identify carers and establish what support they need. This included ensuring information was readily available and checking with patients when they attended appointments.

At this inspection we found that the practice had addressed all the concerns raised and is now rated as good for providing safe and well-led services.

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

  • Ensure national guidelines for children who do not attend for hospital events are followed at all times.
  • Ensure that records detailing significant events are fully completed to confirm the proactive and ongoing review of all events and include details of who the learning from events were shared with.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fordhouses Medical Centre on Wednesday 13 July 2016. Overall the practice is rated as requires improvement.

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

  • Staff understood their responsibilities to raise concerns and to report incidents and near misses; however the practice did not have a formal system in place for the ongoing monitoring of significant events, incidents and accidents.
  • Arrangements were not in place to ensure that all risks to patients were assessed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. The practice was equipped to treat patients and meet their needs.
  • The practice had a programme of continuous clinical and internal audit in order to monitor quality and make improvements.
  • The practice had not ensured that all staff attended training to update their knowledge and skills relevant to their role.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available but not easily accessible to patients.
  • Patients were concerned about the length of time they waited to get a routine appointment and the time spent waiting to be seen at an appointment.
  • There was a clear leadership structure and staff felt supported by the management.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

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

  • Complete employment checks as required by legislation for all staff employed and ensure information in respect of persons employed by the practice is held.
  • Ensure staff members undertaking chaperone duties have received a satisfactory DBS check or have been risk assessed in the absence of a DBS check.
  • Introduce a system to demonstrate the action taken in relation to medicine alerts.
  • Ensure that staff performing clinical tasks, who are not professionally registered, are competent and have appropriate supervision and support.
  • Ensure the practice undertakes a Legionella risk assessment.

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

  • Review the practice’s system for the ongoing monitoring of significant events, incidents, near misses and sharing safety alerts with staff with a view to preventing further occurrences and, ensuring that improvements made are appropriate.
  • Review staff training to ensure that all staff have the appropriate training and skills to carry out their role.
  • Review systems so that patients have ease of access to complaint leaflets and do not have to ask for them.
  • Consider pro-actively identifying carers and establishing what support they need.
  • Review the arrangements for recording minutes of meetings so that staff involvement in decisions made are clearly demonstrated.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 June 2014

During a routine inspection

We previously inspected Fordhouses Medical Centre 24 June 2013. At the time we found that arrangements were in place to ensure people using the service were supported to express their views. Audits were carried out to check safety and suitability of equipment. However there were no systems in place to monitor and review any actions required to address issues found, and to complete the quality assurance process. We judged that this had a minor impact on patients who used the service.

We set compliance actions and told the provider to improve. The provider sent us an action plan following our visit which recorded the actions taken to address the issues raised.

At this inspection visit we looked to see what improvements had been made. We met the GP (who was the provider); we spoke with the practice manager, two staff members and one patient who was visiting the surgery at the time of our inspection. There was also a branch surgery at another location. We visited this location to ensure improvements had also been made to the branch surgery.

We gave short notice of this inspection so that any disruption to people's care and treatment were minimised. At this inspection We found that the practice had taken action to improve the service patients received

24 June 2013

During a routine inspection

During our inspection on 24 and 25 June 2013, people we spoke with had mixed views about the care they received. One person told us: 'The nurses are lovely.' Another person told us they were unhappy with long waiting times for appointments.

People told us that staff treated them respectfully. We saw that reception staff spoke politely to people and consultations were carried out in private treatment rooms. Staff received training in mandatory core subjects

Information was clearly displayed for people, including health promotion, access to support services and information about the practice and the services provided.

Arrangements were in place to ensure people using the service were supported to express their views. Audits were carried out to check safety and suitability of equipment. However there were no systems in place to monitor and review any actions required to address issues found, and to complete the quality assurance process.