The Care Quality Commission
  • Doctor
  • GP practice

Dr Isam Saleh Also known as Wenlock Surgery

Overall: Inadequate read more about inspection ratings

Wenlock Surgery, 40 Wenlock Street, Luton, Bedfordshire, LU2 0NN 0844 576 9785

Provided and run by:
Dr Isam Saleh

Important: We are carrying out a review of quality at Dr Isam Saleh. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

1 June 2023

During an inspection looking at part of the service

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

7 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Isam Saleh on 7 December 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The national GP patient survey asked patients if they felt they were treated with compassion, dignity and respect. The practice was below average for its satisfaction scores on consultations with GPs and nurses. However, the information we received on the CQC comments cards did not reflect the national GP patient survey results. There were 88 comment cards completed and they all had positive remarks about the practice.
  • The practice had an effective system in place for handling complaints and concerns. Information about services and how to complain was available and easy to understand. For example, there were posters and leaflets in the patient waiting area and information on the practice website. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 provider was aware of and complied with the requirements of the duty of candour.
  • A practice charter was displayed in the waiting area and on the practice website.
  • The practice had a patient participation group (PPG) but they had not secured regular attendance from its members. There were posters in the patient waiting area and information on the practice website advertising for new members to the PPG.
  • The practice had been recognised by Live Well Luton as the top performing practice in Luton for providing in house smoking cessation advice in 2016.

The areas where the provider should make improvement are:

  • Implement a system to monitor the use of blank prescription forms and pads in the practice.
  • Encourage patients to attend the national screening programmes for bowel and breast cancer screening.
  • Continue to monitor and ensure improvements to national patient survey results particularly in relation to, treating patients with compassion, dignity and respect and involving patients in planning and making decisions about their care and treatment.
  • Consider identifying a member of staff as a carers lead to continue to identify and support carers.
  • Continue to establish the patient participation group (PPG).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice