Archived: Brace Street Health Centre

Updated 8 November 2023

Dr Mahbub’s Medical Centre is located in Walsall at:

Dr Mahbub’s Surgery

Brace Street Health Centre

Walsall

WS1 3PS

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Black Country Integrated Care System (ICS) and delivers General Medical Services (GMS). This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices forming a primary care network (PCN) named South 1 PCN Service, a group of 9 practices within the local region.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the lowest decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others.

The practice has a 3170-patient list. According to the latest available data, the ethnic make-up of the practice area is 47.5% Asian, 41.5% White, 5.4% Black, 4.1% Mixed, and 1.5% Other.

The age distribution of the practice population shows a high level of children at 30.5% compared to an England average of 19.9% and a low older people population of 7.4% compared to the England average 17.7%. There are more male patients registered at the practice compared to females.

The surgery works closely with another surgery in Dudley which the lead GP also owns, and they share some of the same staff.

The partnership team consist of one GP and a part time practice manager, who is also a part time nurse. The practice employs a further full-time nurse, a part time pharmacist and a physician associate and a paramedic, there are also 3 regular locum GP’s which work with the practice. The GPs are supported at the practice by a team of reception/administration staff. The practice manager is based at this location to provide managerial oversight.

The practice is open between 0800 to 1830 Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the PCN where late evening and weekend appointments are available. Out of hours services are provided by 111.

Updated 8 November 2023

We carried out an unannounced comprehensive inspection at Dr Mahbub’s Surgery on 20th June 2023. Overall, the practice is rated as inadequate.

Safe - inadequate,

Effective - inadequate,

Caring - requires improvement,

Responsive - inadequate,

Well-led - inadequate,

Following our previous inspection on 20th March 2018, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Mahbub’s surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up concerns reported to us.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• The practice was unable to demonstrate they had systems in place to ensure the safe management of patient care.
• The practice was unable to demonstrate that they were providing effective services, they showed limited monitoring of outcomes of treatment, and they were unable to demonstrate that staff had the skills, knowledge and experience required to carry out their role.
• Staff did not always have the information they needed to deliver safe care and treatment.
• The practice safeguarding registers had not been maintained appropriately and the information held was inaccurate.
• The practice could not demonstrate effective clinical oversight of staff undertaking clinical roles to ensure they were working within their competencies. We found significant concerns in the prescribing of medicines and gaps in the information recorded in patients’ consultation records.
• We found there was no systematic structured approach with effective clinical oversight of patient information including clinical data.
• The practice was unable to demonstrate that incidents that affect the health, safety and welfare of people using services were reported internally and had been shared with staff to promote learning and improvement.
• The practice was not always responsive to the needs of their patients in accessing appointments and medicines and complaints were not always used to improve the quality of care.
• The practice was unable to demonstrate they had effective leadership or the correct culture in place to provide high quality sustainable care.
• The practice did not have fully embedded governance systems and had not proactively identified and managed risks.
• The overall governance arrangements were ineffective. The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice was unable to demonstrate that they involved patients, staff or stakeholders in shaping the service.

We found 4 breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure there are comprehensive systems in place to respond to complaints in a timely manner ensuring learning is identified to reduce the likelihood of recurrence.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

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

• Implement a process to encourage patients to attend for cervical and breast cancer screening.
• Implement a carer’s register.

As a result of the inspection team’s findings from the inspection, as to non-compliance, but more seriously, the risk to service users’ life, health and wellbeing, the Commission decided to issue an urgent notice of decision to impose conditions on the provider’s registration. The notice was served on the provider on 6 July 2023 and took immediate effect.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, 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. Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care