Dr Isam Saleh Also known as Wenlock Surgery

Updated 24 January 2024

Dr Isam Saleh, also known as Wenlock Surgery, is located in the High Town area of Luton at:

Dr. Isam Saleh

Wenlock Surgery

40 Wenlock Street

Luton

Bedfordshire

LU2 0NN

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.

The practice is situated within the Bedfordshire, Luton and Milton Keynes Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 3,500. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices that includes 8 other local GP practices.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fourth lowest decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 25% Asian, 58% White, 10% Black, 5% Mixed, and 2% Other.

The age distribution of the practice population shows a higher proportion of working age people and young people and a lower proportion of older people when compared with the local and national averages. There are more male patients registered at the practice compared to females.

There was one principal GP who at the time of inspection was supported by a GP partner who also employed 2 locum GPs. The CQC registration had not been amended to reflect this partnership and the partnership was being dissolved during the inspection period. The practice has two practice nurses and a phlebotomist. The GPs are supported at the practice by a practice manager and a team of reception/administration staff.

The practice is open between 8am to 6.30pm Monday, Wednesday, Thursday and Friday and between 8am and 1pm Tuesday. The practice offers a range of appointment types including book on the day, a walk-in service, telephone consultations and advance appointments.

Extended access is provided locally by the Luton extended access service, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.

Updated 24 January 2024

We carried out an announced focused inspection at Dr Isam Saleh on 1 June 2023. Overall, the practice is rated as inadequate.

Safe - Inadequate.

Effective – Inadequate.

Caring – Rating of good, carried forward from previous inspection.

Responsive – Requires improvement.

Well-led – Inadequate.

Following our previous inspection on 7 December 2016, 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 Isam Saleh 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 in response to risk in line with our inspection priorities. During the inspection we reviewed 4 of our 5 key questions, safe, effective, responsive and well-led.

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:

• Conducting staff interviews using video conferencing.
• 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 did not provide care in a way that kept patients safe and protected them from avoidable harm.
• The practice did not have an effective system to ensure patients on medicines that required monitoring were appropriately managed in a timely way.
• The practice was not effectively assessing the risk of preventing and controlling the spread of infections.
• Medicines and equipment were not being managed in a safe and effective manner.
• Prescriptions were not kept securely, and their use was not monitored in line with national guidance.
• Safeguarding processes were not safe or effective.
• Patient records of care and treatment were not managed in a safe and effective way.
• Patients did not always receive effective care and treatment that met their needs. Their needs were not assessed and care and treatment was not always delivered in line with current legislation, standards and guidance.
• The system for monitoring patients with long-term conditions was ineffective.
• There were not effective processes in place to ensure that persons had access to and received cervical cancer screening.
• The practice facilities were not being managed appropriately for the services being delivered.
• Learning from complaints was not used to improve the quality of care.
• The way the practice was led and managed did not promote the delivery of high-quality, person-centred care.
• There were ineffective systems in place for the management of significant events.
• There was not an effective system to ensure that staff working in the practice completed the required training as directed by the practice policies.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.

We found multiple breaches of regulations.

• Care and treatment was not provided in a safe way to patients.
• Patients were not protected from abuse and improper treatment.
• Premises and equipment used by the service provider was not fit for use.
• Effective systems and processes to ensure good governance in accordance with the fundamental standards of care were not established.

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

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care