The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Prosanta Kumar Sarkar

Overall: Inadequate read more about inspection ratings

73 Bath Street, Sedgley, Dudley, West Midlands, DY3 1LS (01902) 887870

Provided and run by:
Dr Prosanta Kumar Sarkar

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

All Inspections

24 November 2015 and 26 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bath Street Medical Centre on 24 November 2015 and an unannounced follow up inspection on 26 November 2015. Overall the practice is rated as inadequate.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, our review of specific minor surgery procedures carried out by one of the GPs highlighted that patients were at risk of harm because the GP was not following the current referral guidelines.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, we found that some significant events had not been recorded and that the practice could not demonstrate a safe track record of incidents over time.
  • Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement.
  • Arrangements were in place to safeguard children and vulnerable adults from abuse that reflected relevant legislation and local requirements.
  • There were systems in place for repeat prescribing and a system in place for the prescribing of high risk medicines. However, some records we viewed highlighted that medication reviews had not taken place within the relevant 12 month period.
  • Patients we spoke with on the day of our inspection were positive about their interactions with staff and said they were treated with compassion and dignity.
  • Data showed that patients rated the practice lower than others for some aspects of care and appointment waiting times.
  • The practice had a number of policies and procedures to govern activity. However, we found that governance arrangement were not always robust.
  • Prescription pads used for home visits were stored securely however the practice did not have a system in place to track and monitor their use.
  • We did not see evidence to support that staff were up to date with some of the immunisations recommended for staff who work in general practice.

The areas where the provider must make improvements are:

During our inspection on 24 November 2015 we identified a number of cases where a GP had not followed current guidelines in relation to referrals for suspected melanoma. The Care Quality Commission contacted the GP in question on 27 November 2015 to request that the GP stopped performing minor surgery as a matter of urgency. The GP in question confirmed in writing that they would stop providing minor surgery from 27 November 2015 and that another GP in the practice would perform this service when required.

  • The provider must ensure that they continue to comply with this arrangement.
  • The provider must ensure systems are in place so that all clinicians are kept up to date with national guidance and guidelines.
  • The provider must carry out clinical audits including re-audits to ensure improvements have been identified and achieved and improve governance arrangements including systems for recording, assessing and mitigating risks across the practice.
  • The provider must ensure processes are robust for reporting and managing significant events, incidents and near misses, ensure all events are recorded.
  • The provider must improve recall and review systems to ensure patient care, treatment and medication are regularly reviewed.
  • The provider must ensure the use of prescriptions used during home visits are clearly tracked and monitored.

The areas where the provider should make improvement are:

  • Address areas for improvement highlighted through patient feedback such as national survey results.
  • Improve minutes of meetings to clearly document discussions which take place and record and review actions required.
  • Ensure staff are up to date with relevant routine immunisations.

I am placing this practice in special measures. Practices 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 population group, 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

This was a follow up inspection from our inspection on 6 August 2013. We did not speak to patients as part of this inspection because the improvements we required the provider to make were concerned with staff training and administrative matters. We spoke to two staff.

At our previous inspection we found improvements were required to staff knowledge of infection control procedures and practice. Staff attended training in November 2013 and had updated policies and procedures. This meant they had obtained the skills and knowledge to reduce the risk of patients, staff and visitors obtaining an infection.

At the 6 August 2013 inspection we found improvements were required to patient engagement to improve the quality of service provided. The practice introduced a patient participation group (PPG) in November 2013. In December 2013 questionnaires were sent to obtain patient feedback on the quality of service provided. These were analysed and actions had been taken to address patients' concerns. This demonstrated active engagement with patients to provide ongoing improvements within the practice.

6 August 2013

During a routine inspection

On the day of our inspection we spoke with six patients and seven members of staff. One patient said, 'It is superb, I wouldn't want to go anywhere else." The patients we spoke with said they were able to obtain appointments at a time to suit their needs and that they did not have to wait long once they arrived at the practice.

We saw that patient's views and experiences were taken into account in the way the service was provided and that they were treated with dignity and respect. One patient told us, 'They have a lovely bedside manner." We saw that patients experienced care and treatment that met their needs. Patients told us and we saw that care was delivered in a clean environment. Improvements were required to the infection control systems to ensure that the most up to date practice was implemented.

Staff were knowledgeable about the protection of vulnerable adults and children and were aware of the appropriate reporting methods required.

There were systems in place to assess and monitor the quality of service that people received. Improvements were required to ensure that patient feedback was incorporated into the quality improvement systems of the practice.