The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Syed Ayaz Ahmed

Overall: Requires improvement read more about inspection ratings

Village Medical Centre, 158a Crankhall Lane, Wednesbury, West Midlands, WS10 0EB (0121) 556 2233

Provided and run by:
Dr Syed Ayaz Ahmed

All Inspections

18 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at Dr Syed Ayaz Ahmed (also known as Village Medical Centre) on 18 December 2019, following our annual regulatory review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.

This inspection focused on all of the following key questions:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led

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 requires improvement overall.

We rated the practice as requires improvement for providing safe, effective, responsive and well led services.

  • There were some systems and processes in place to keep people safe. However, these were not always identified, sufficiently well managed or embedded to ensure their effectiveness.
  • Improvements were required in the management of patients with long term conditions such as those with diabetes and chronic obstructive pulmonary disease.
  • The uptake of cervical screening was below the national minimum standards. Although the practice had taken some action to improve, the practice could not yet demonstrate this had resulted in significant improvements.
  • People were not always able to access care and treatment in a timely way.
  • There was no effective system in place to obtain patient feedback to improve the service.
  • There was a lack of effective leadership and oversight to ensure good governance. The practice did not always have clear and effective processes for identifying and managing risks, issues and performance.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was overall positive. This included the results of the national GP survey which showed the practice was mostly similar to the local and national average in questions relating to caring.

The areas where the provider must make improvements are:

  • 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).

The areas where the provider should make improvements are:

  • Consider how to increase the uptake for cervical screening so the minimum coverage target for the national screening programme is met.
  • Consider how to further improve the management of patients with long term conditions such as those with diabetes and chronic obstructive pulmonary disease.
  • Review the information in the patient waiting area to raise patient’s awareness on services and support available for example, carers and those with communication needs. Make clear the arrangements in place to ensure confidentiality at the reception desk.
  • Consider developing a practice website to ensure information is accessible to patients.

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


25 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Syed Ayaz Ahmed on10 May 2016. The overall rating for the practice was requires improvement. The full comprehensive report for the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Syed Ayaz Ahmed on our website at www.cqc.org.uk.

This planned inspection was undertaken to follow up progress made by the practice since the inspection on 10 May 2016. It was an announced comprehensive inspection on 25 April 2017. Overall the practice is now rated as good.

  • During our previous inspection in May 2016 we saw that there was a system in place for reporting and recording significant events. However, we saw an example of where a non-clinical incident was not recorded. During this follow up comprehensive inspection, we saw improvements had been made to the incident reporting process.
  • When we inspected the practice in May 2016 we saw processes were not always in place to keep patients safe through appropriate recruitment checks. The practice had not recruited any new staff members since our previous inspection. However, there were plans to recruit new staff. We saw recruitment processes were in place and were assured appropriate recruitment and selection procedure such background and employment history checks would be followed when recruiting new staff.
  • During our previous inspection we saw patient clinical outcomes data were low compared to the local CCG and national averages. Data reviewed prior to this follow up inspection also showed low patient outcomes data. On the day of the inspection unpublished and unverified data was available. We looked at the practice record system which demonstrated significant improvements had taken place.
  • Previously we were unable to fully identify patient outcomes as audits did not demonstrate quality improvement and there was little evidence that the practice had developed formal care plans for patients in need of extra support. During this follow up inspection we saw evidence that formal care plans had been developed and the practice was able to demonstrate quality improvement through completed audit cycles.
  • 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. We saw an example of an audit that was based on NICE guidance.
  • When we inspected in May 2016, the practice was unable to provide evidence that a carers register was in place. At this follow up, the practice was able to demonstrate that a register was in place. We saw 108 carers had been identified (1.5% of the practice list size) and offered further support where appropriate.
  • 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.
  • National GP patient results also showed that patient’s satisfaction with how they could access care and treatment was comparable to local averages, but below national averages. The practice planned to become a hub for one of the five local commissioning groups that made up the CCG from September 2017. This would enable the practice to offer access from 8am to 8pm every day and plans were also in place to increase the number of telephone lines and reception staff.
  • Previously, we noted that the practice complaints process was not displayed to inform patients of the process. During this inspection we saw complaints leaflets were available and the process for making complaints was displayed in the reception area.
  • The lead GP told us that they had increased the number of sessions they offered since the last inspection and patients we spoke with said they found it easier to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice was located in purpose built premises and had good facilities to meet patient needs.

The areas where the provider should make improvement are:

  • The practice should consider keeping checked copies of proof of identification on file following Disclosure and Barring Service (DBS) checks.
  • Continue to review and develop business continuity plan to ensure it is fit for purpose.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Syed Ayaz Ahmed also known as Village Medical Centre on 10 May 2016. Overall the practice is rated as Requires Improvement.

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

  • There was a system in place for reporting and recording significant events. However, we saw an example of where a non-clinical incident was not recorded.

  • Processes were not always in place to keep patients safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment
  • Patient outcomes were hard to identify as audits did not demonstrate quality improvement and there was little evidence that the practice had developed formal care plans for patients in need of extra support.
  • Data showed patient outcomes were low compared to the national average.
  • Some patients said they found it difficult to make an appointment with a named GP as all the GPs worked different days. National patient survey data showed that patient’s satisfaction with how they could access care and treatment was lower than the national average.
  • Patients we spoke with on the day said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • When asked the practice did not provide evidence that a carers register was in place in order to identify and further support these patients.
  • The practice complaints process was not displayed for the benefit of patients at the time of the inspection. However, improvements were made to the quality of care when complaints and concerns were received.
  • There was leadership structure and staff felt supported by management. However, systems or processes were not established or operated effectively to assess, monitor and improve the quality and safety of the services.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review.

The areas where the provider must make improvement are:

  • Ensure all patient safety alerts are responded to appropriately.
  • Carry out risk assessments for legionella and COSHH.
  • Recruitment procedures must be established and operated effectively
  • Ensure formal care plans for relevant patients are developed.

The areas where the provider should make improvement are:

  • Ensure all non clinical incidents are documented in order to identify and share learning.
  • All incoming clinical letters should be reviewed by clinical staff.
  • Consider how to further improve on the system for identifying and supporting carers
  • Ensure patients are informed of the complaints procedure in the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 November 2013

During a routine inspection

On the day of the inspection we spoke with three staff members, the principal GP and the practice manager. We also spoke with seven patients about their experience. One patient said: 'To be quite honest I've got no complaints. Staff are well mannered, you get a smile when you walk in.' Another patient said: 'It's good. They've done everything I've asked.'

We found that care and treatment was planned and delivered in a way that met patients' needs. Patients we spoke with told us they were generally happy with the level of care they had received.

Staff had received training in safeguarding and were aware of the appropriate agencies to refer safeguarding concerns to. This ensured that patients were protected from harm.

We found that staff had received appropriate training for the roles they carried out. They also had regular appraisals. This meant that they had been adequately assessed as being competent.

The provider had systems in place for monitoring the quality of service provision. We saw that the practice carried out a range of audits to monitor the quality of its own performance and the level of service being delivered.