The Care Quality Commission
  • Doctor
  • GP practice

Modality Darlaston Practice

Overall: Good read more about inspection ratings

Pinfold Street, Wednesbury, West Midlands, WS10 8SY (0121) 817 0710

Provided and run by:
Modality Partnership

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 Modality Darlaston Practice 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 Modality Darlaston Practice, you can give feedback on this service.

19 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at Modality Darlaston Practice on 19 June 2019 as part of our inspection programme.

At our last inspection in July 2018, we rated the practice as requires improvement for providing safe and well led services because:

  • Risk assessments were not on file for staff who started prior to receipt of a Disclosure and Barring Service (DBS) check.
  • Not all required recruitment information was available in staff files.
  • There was a lack of oversight of renewal dates for professional registrations, training files and staff records.
  • Not all staff were up to date with essential training.
  • Limited numbers of significant events were recorded and there was no evidence to support that the practice had reviewed previous events to identify themes.
  • Complaints had not been investigated and responded to in line with the provider’s policy and procedure.
  • The practice had not been proactive in managing changes to staffing or assessed and monitored the impact on safety.

Requirement notices in relation to safe care and treatment and fit and proper persons employed were served. The full comprehensive report for the July 2018 inspection can be found by selecting the ‘all reports’ link for Modality Darlaston Practice on our website at www.cqc.org.uk.

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.

We found that:

  • The practice had made improvements since our inspection on July 2018, and leaders demonstrated that they had the capacity and skills to deliver high quality, sustainable care.
  • The practice had made improvements so that it provided care in a way that kept patients safe and protected them from avoidable harm.
  • Improvements had been made to the management of risk and learning from significant events.
  • The practice had addressed the shortfalls in staffing through the use of locum clinical staff.
  • 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.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Effective systems and processes had been introduced to ensure good governance.
  • The practice was making use of IT systems to improve services for patients. This included video consultations via smart phones, and MJOG text messaging services.

The areas where the provider should make improvements are:

  • Consider ways to increase the uptake of national programmes such as cervical screening, bowel cancer screening and childhood immunisations.
  • Notify the Care Quality Commission as required of incidents, events and changes that affect a service or the people using it.

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

10 July 2018

During a routine inspection

The practice is rated as Requires Improvement overall (previous rating July 2017 – Requires Improvement)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We previously undertook a comprehensive inspection of Dr Sundar Vaid 6 July 2017. The overall rating for the practice was Requires Improvement with the Effective and Caring domains being rated as Requires Improvement. This was because the practice was not following Gillick guidelines in relation to caring for and treating children under 16 years old.

The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Dr Sundar Vaid on our website at www.cqc.org.uk.

Dr Sundar Vaid and Dr Saptarshi Saha’s practices merged on 1 January 2018. We previously undertook a comprehensive inspection of Dr Saptarshi Saha on 11 April 2017 and the overall rating was Good.

The full comprehensive report on the April 2017 inspection can be found by selecting the ‘all reports’ link for Dr Saptarshi Saha on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 10 July 2018 to confirm that the practice met the legal requirement in relation to the breach in regulation that we identified in our previous inspection on 6 July 2017.

At this inspection we found:

  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice opening hours had been increased to five days a week.
  • Patients were able to access appointments when they needed them.
  • Policies and procedures were in place to manage risk, although they were not all being used effectively.
  • The practice had not obtained all of the required recruitment information for newly employed staff or ensured that they completed the induction programme.
  • There was some evidence that quality and operational information was reviewed to try to improve performance.
  • There was some evidence of systems and processes for learning, continuous learning and innovation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure specified information is available regarding each person employed recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Establish effective systems and processes to ensure good governance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • All staff should be aware of which clinician is the safeguarding lead.
  • The induction programme should be completed by all new staff.
  • Consider formally monitoring the prescribing of controlled drugs.
  • GPs should be aware of the arrangements for reporting concerns around controlled drugs with the NHS Area Team Controlled Drugs Accountable Officer.
  • Consider holding formal meetings with the Health Visitors.
  • Consider ways to increase the uptake of national programmes such as cervical screening and childhood immunisations.
  • Recommence palliative care meetings.
  • Improve staff awareness of the provider’s vision and values.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

6 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sundar Vaid’s practice on 6 July 2017. Overall the practice is rated as Requires Improvement.

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. Staff had regular meetings to discuss significant events and lessons learnt.
  • The practice was not following the Gillick guidelines in relation to providing care and treatment for children under the age of 16 years of age. The practice told us they did not allow children to have a consultation without the presence of an adult.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety, this included an effective process for monitoring and actioning safety alerts.
  • 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.
  • Clinical audits demonstrated quality improvement and the practice carried out regular audits to monitor patient outcomes.
  • Overall Quality Outcomes Framework (QOF) performance was above local and national averages.
  • The practice had clearly defined and embedded systems to minimise risks associated with legionella, fire and health & safety.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Completed Care Quality Commission comment cards we received showed patients were satisfied with the care and treatment they received, however the GP national patient survey showed lower results for consultations with the GP in comparison to local and national averages.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.
  • 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 practice had an active patient participation group (PPG) and we saw measures in place in order to increase PPG membership.
  • The GP encouraged a culture of openness and honesty. The practice had a well established governance framework to support the delivery of safe and effective care.

There was an area where the provider must make improvements:

The provider must:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences

There were also areas of practice where the provider should make improvements.

The provider should:

  • Establish processes to increase the identification of carers in order to provide further support where needed.
  • Review the current opening hours to ensure care is provided in response to patients needs.
  • Continue to review national GP patient survey results and explore effective ways to further improve patient satisfaction scores.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice