The Care Quality Commission
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  • GP practice

Archived: Dr Mahbub's Surgery

Overall: Inadequate read more about inspection ratings

Brace Street Health Centre, Brace Street, Walsall, WS1 3PS (01922) 605910

Provided and run by:
Dr Mahbub's Surgery

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

All Inspections

20 June 2023

During an inspection looking at part of the service

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

18 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Mahbub’s Surgery on 2 June 2017. The overall rating for the practice was requires improvement, with an inadequate rating for providing effective services. This was because the management of patient information was not effective.

The full comprehensive report on the June 2017 inspection can be found by selecting the ‘all reports’ link for Dr Mahbub’s Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 18 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 2 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

This practice is rated as Good overall. (The practice was rated requires improvement at our previous inspection on 2 June 2017).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

Our key findings were as follows:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learnt from them and improved their processes.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • The practice worked closely with other health and social care professionals involved in patient’s care. Regular meetings were held with the community nursing teams and palliative care teams to discuss the care of patients who were frail / vulnerable or who were receiving end of life care.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Patients commented that they were treated with compassion, kindness, dignity and respect.
  • We found that some of the scores, particularly those for the nurses in the GP Patient Survey published July 2017 were lower than the scores in the July 2016 survey. However, the practice had carried out its own patient satisfaction survey and taken action to address the identified issues.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

There were also areas of practice where the provider should make improvements:

  • Review and update the safeguarding policies to include current guidance on modern slavery and female genital mutilation.
  • Update the risk assessment of emergency medicines to decide whether a medicine to treat croup in children should be available.
  • Update the risk assessments to include blind cords.
  • Review the process in place to ensure the identification of significant events.
  • Explore ways to improve the uptake of national screening programmes.
  • Explore the reasons for the decrease in the national GP survey, especially in relation to the nursing staff, in order to improve patient satisfaction in all areas.
  • Consider increasing the availability of on line appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mahbub’s Surgery on 2 June 2017. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence of learning from incidents. Patients received a verbal apology.
  • Risks to patients were generally assessed and well managed, the exception being a lack of clarity of the processes for changing prescriptions and ensuring authorisation by a prescriber.
  • Data for 2015/16 showed patient outcomes were low compared to the national average. Although, improvement was seen within the unvalidated data for 2016/17.
  • There was some evidence of audits that had been carried out to support improvements in patient outcomes.
  • We identified concerns in the management of patient information which had led to two delayed referrals. Following the inspection the provider had reviewed the back log of correspondence to ensure appropriate action had been taken as well as action to mitigate future risk.
  • Data from the latest national patient survey was lower than CCG and national averages in relation to patient satisfaction on consultations and helpfulness of reception staff. Although the practices own in-patient survey and feedback from CQC comment cards was more positive.
  • Not all patients we spoke with said they found it easy to make an appointment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had a number of policies and procedures in place to govern activity.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The patient participation group was relatively new and had yet to demonstrate any clear impact on service improvement.

The areas where the provider must make improvements are:

  • Ensure effective systems for managing patient information to ensure care and treatment is provided to patients in a safe way.

In addition the provider should:

  • Identify further ways to improve on patient outcome data and uptake of national screening programmes.
  • Formalise and monitor the procedure in place to ensure amendments to medication are overseen and authorised by the prescriber.

  • Review and implement ways in which the identification of carers might be improved.

  • Review availability of practice nurse appointments to reflect the need of patients.
  • Ensure feedback received from patients such as the national GP patient survey is reviewed to identify how patient satisfaction with services could be improved and acted on. Identify ways in which the patient voice may be improved in supporting service improvement.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice