The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Rameshchandra Manilal Shah Also known as Thorns Road Surgery

Overall: Good read more about inspection ratings

43 Thorns Road, Quarry Bank, Brierley Hill, West Midlands, DY5 2JS (01384) 484894

Provided and run by:
Dr Rameshchandra Manilal Shah

Important: The provider of this service changed. See new profile

All Inspections

21 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of Dr Rameshchandra Manilal Shah’s practice, at Thorns Road Surgery, in October 2015. As a result of our comprehensive inspection breaches of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified some areas where the provider must make improvements and additional areas where the provider should improve.

We carried out a focussed desk based inspection of Dr Rameshchandra Manilal Shah’s practice, at Thorns Road Surgery on 21 October 2016 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Rameshchandra Manilal Shah on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:

  • Since our comprehensive inspection in October 2015, the practice had applied for disclosure and barring (DBS) checks for non-clinical staff members who chaperoned and for the practice nurse. We saw evidence to support this as part of our desk based inspection.
  • Records demonstrated that the cold chain was appropriately monitored. Conversations with the practice manager also confirmed that the practice followed appropriate cold chain processes in line with national guidelines, such as appropriate temperature recording and ensuring that thermometers were reset after each recording.
  • Regular fire drills were taking place and there were risk assessments in place to assess risks associated with infection control including a formal risk assessment for legionella.
  • We also saw that risk had been assessed in the absence of a defibrillator and although the risk was assessed as low the practice had noted that they would prefer to purchase a defibrillator as soon as the funding became available.

The areas where the provider should make improvements are:

  • The provider should ensure that in the absence of specific emergency medical equipment, risk is continually monitored and effectively mitigated to ensure that the practice can immediately respond to medical emergencies, for instance in the absence of a defibrillator.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Rameshchandra Manilal Shahs practice (Thorns Road Surgery) on 14 October 2015. Overall the practice is rated as good.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • Some risks to patients who used services were assessed. However we found that risk assessments were not in place to assess a number of risks across the practice.
  • The practice had an up to date fire risk assessment and completed weekly fire alarm tests. However, staff we spoke with confirmed that regular fire drills had not taken place.
  • The practices recruitment checks were not robust, the practice did not complete a disclosure and barring check (DBS) for their nurse.
  • The practice did not correctly monitor the temperature of the vaccination fridges and therefore adherence to cold chain procedures was not robust.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • 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.

However there were areas of practice where the provider needs to make improvements.

The areas where the provider must make improvements are:

  • Assess and manage risks associated with legionella and to assess the risk of not having disclosure and barring checks (DBS) for the practice nurse and for staff that chaperone.
  • Ensure fridge temperatures are recorded correctly, in line with national guidance, to ensure robust maintenance of the cold chain.

The areas where the provider should make improvement are :

  • Ensure regular fire drills take place within the practice.
  • Analyse feedback from external and internal surveys to ensure patient needs are listened to and used to drive improvements to the quality and safety of services.
  • Assess and manage risks in the absence of emergency medical equipment that reflects national standards

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice