The Care Quality Commission
  • Doctor
  • GP practice

Naseby Medical Centre

Overall: Inadequate read more about inspection ratings

32-34 Naseby Road, Saltley, Birmingham, West Midlands, B8 3HE (0121) 327 1878

Provided and run by:
Naseby Medical Centre

Important:

We urgently suspended the registration of Naseby Medical Centre on 7 August 2025 for serious breaches of regulations relating to safe care and treatment and good governance that will or may expose a person to the risk of harm if we do not take this action.

All Inspections

During an assessment under our new approach

Date of Inspection: 16 January 2026 to 7 February 2026. Naseby Medical Centre is a GP practice and delivers service to 5,500 people under a contract held with NHS England. The National General Practice Profiles states that the practice population is 59.8% Asian, 20.8% White, 10.3% Black, 3.4% Mixed and 5.8% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 1st decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. This inspection considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

On 7 August 2025 the Care Quality Commission (CQC) urgently suspended the registration of Naseby Medical Centre in response to serious concerns identified during an inspection in July and August 2025. As a result of these concerns we took urgent action to protect the safety and welfare of people using this service. Under Section 31 of the Health and Social Care Act 2008 we imposed a temporary suspension of six months on the registration of the provider in respect of the following activities: Diagnostic and screening procedures, Maternity and midwifery services and Treatment of disease, disorder or injury.

We carried out a focused assessment to establish if the provider, Naseby Medical Centre could resume the delivery of regulated activities or the suspension must be extended further.

We identified that whilst the provider had made some progress towards rectifying the serious concerns the CQC had identified, the provider was unable to demonstrate that effective governance arrangements would be implemented to manage risks, performance and deliver safe care to patients who used the service.


The leadership team did not demonstrate sufficient understanding of the serious clinical safety and governance failings previously identified, nor had they embedded learning or engaged meaningfully with the caretaker provider to ensure a safe transition of services. Policies had been drafted but not implemented, environmental risks were not effectively managed, and concerns about staff competence and unsuitable staffing plans remained.

There was no assurance of effective systems for managing long‑term conditions, medication reviews, high‑risk medicines, or accurate clinical record‑keeping. Leaders had not reflected on the impact of previous poor‑quality, non‑person‑centred care, and improvement planning remained limited and reactive. While some late actions were taken, they did not provide confidence that safe, well‑governed care could be delivered. Ongoing significant risks led to the suspension of registration being extended for a further three months.
 

During an assessment under our new approach

Date of Assessment: 25 July 2025 to 7 August 2025. Naseby Medical Centre is a GP practice and delivers services to 5,580 patients under a contract held with NHS England. The National General Practice Profiles states that the practice population is 59.8% Asian, 20.8% White, 10.3% Black, 3.4% Mixed and 5.8% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 1st decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. The purpose of this assessment was to review a limited number of quality statements across safe, effective and well-led key questions in response to a Warning Notice issued to Naseby Medical Centre in November 2024. However, due to additional concerns being identified, the scope of our assessment was expanded to include all quality statements under each key questions safe, effective, caring, responsive and well-led on 5 August 2025.

We identified significant and serious concerns with the practice. We were not assured that managers investigated incidents or that people were protected and kept safe. The leadership team did not demonstrate a thorough understanding of risk and how to manage it. There was a lack of clinical staff with the right skills, qualifications and experience to safely manage the number of patients registered with the practice. We were not assured that patients with long-term conditions such as diabetes were being managed effectively or that medicines were prescribed, reviewed and monitored safely. This exposed patients to an unacceptable risk of harm. For example, patients with diabetes who do not have their condition regularly reviewed and managed are at risk of developing serious, life-altering complications such as blindness, amputation or even death.

Our review of clinical records did not assure us that care was based on the latest evidence and good practice. We found that some clinical information entered onto the practice systems was not accurate or up-to-date and this had not been identified or resolved by the practice. This put patients at significant risk of harm because clinical information was incorrect, incomplete or out of date.

Although our clinical searches demonstrated clinicians were carrying out reporting requirements for the calculation of Quality Outcome Framework (QoF) points and payments, we found the ongoing management of patients was not in line with NICE (National Institute for Health and Care Excellence) guidance. In addition, we found that clinicians were not accurately applying clinical diagnosis codes in patients’ records to ensure effective identification of the target population. The clinical lead was unable to demonstrate that there was an effective system in place to maintain a high quality and accurate QoF register. Therefore, we were not assured that all the relevant target populations that met the defined criteria (as outlined in QoF Framework guidance for 2025/26) were included in the registers or that QoF was being used for its intended purpose. QoF is a system used in UK primary care to financially reward general practices for delivering high-quality care based on performance against a set of clinical and public health indicators.

During the assessment we highlighted several serious concerns which exposed the practice patient population to potential harm. However, leaders demonstrated a lack of awareness and insight regarding the impact of these risks, which we brought to their attention.

Staff worked with some agencies involved in people’s care to improve outcomes although we found that managers undertook limited work with the local health community and were not always receptive to new ideas.

At the time of our assessment, the practice was undergoing building work to expand and upgrade facilities for patients. The newly built facilities and equipment met the needs of people. The practice had recently recruited a pharmacist to help them provide the required frequency of medicine and long-term condition reviews. Staff protected patients’ privacy and dignity. Mostly staff treated patients as individuals and people had choice in their care and treatment.

The practice provided information people could understand. There was information at the practice and on the website on how to give feedback. The practice was mostly easy to access. Leaders and staff had a shared vision and culture. Staff said that leaders were visible and supportive, treating them equally without bullying or harassment. However, we found that overall, the culture of the practice was closed and inward facing. There was a lack of evidence to demonstrate the practice had built and maintained the necessary networks and ongoing engagement with external partners within the wider community health landscape.

We found breaches of regulation in relation to safe care and treatment and good governance. 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.
 

During an assessment under our new approach

Naseby Medical Centre is located at 32-34 Naseby Road, Alum Rock, Birmingham, B8 3HE. The practice is situated in a converted house; providing NHS services to the local community. The service is registered with the CQC to deliver the Regulated Activities of Diagnostic and screening procedures, Maternity and midwifery services, and Treatment of disease, disorder or injury. A remote assessment of this service took place on 12 July 2024. Our onsite assessment took place on 9, 10 September 2024. There were approximately 5566 people registered with the service at the time of our assessment. We assessed quality statements across Safe, Effective, Responsive, and Well-led key questions. The practice was in the process of commencing building extension works and an internal refurbishment to improve the facilities and the care provided for patients. At this assessment, our review of clinical records found the practice was not operating an effective, embedded system to ensure patients received necessary and timely monitoring, blood tests and medication reviews across a range of medical conditions. We were not assured ongoing long term condition needs were fully assessed for all patients. In addition, we were not assured the practice was operating effective and embedded safeguarding systems and processes to safeguard patients from abuse. Our assessment also found the arrangements for clinical supervision of staff required improvement.

30 September 2020 and 14 December 2020

During an inspection looking at part of the service

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the COVID-19 pandemic. This was conducted with the consent of the provider.

At the last inspection in November 2019 we rated the practice as requires improvement overall; however, the practice was rated good in caring and responsive because:

  • Training records for clinical staff who were not directly employed by the practice did not demonstrate that they were up to date with child safeguarding training and there were limited evidence of engagement with external healthcare professionals. Following our inspection, the provider submitted evidence demonstrating training and engagement.
  • There were areas where clinical outcomes and screening rates were significantly below national averages or targets.
  • The governance arrangements’ for managing the oversight of training, employment checks and embedding processes for recording significant events was not managed effectively.

We carried out an announced focused inspection at Naseby Medical Centre as part of our pilot inspection programme. The inspection consisted of remote interviews on 24 September 2020 and visiting the provider on 30th September 2020. A further site visit was carried out on 14th December 2020 to gain further information on how the provider managed people’s clinical needs. We decided to undertake the focus inspection in response to risk. This inspection looked at all five key questions.

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 have rated this practice as good overall and requires improvement for families, children and young people as well as working age people (including those recently retired and students) population groups.

We rated the practice as good for providing safe, caring, responsive and well-led services because:

  • Staff articulated how they ensured patients were dealt with kindness and respect and involved them in decisions about their care.
  • The 2020 national GP survey showed areas where patient satisfaction was above local and national averages. This was aligned with feedback from the practices internal 2020 patient survey
  • The practice had an action plan aimed at improving patient access. For example, the practice demonstrated how they were seeking to upgrade the telecommunication system and patients were encouraged to use online services as a way of reducing the volume of incoming calls. The 2020 national GP patient survey showed patients were satisfied with their overall experience of making an appointment and with the appointment times.
  • The practice had increased capacity within the nursing team which enabled the practice to offer more appointments for cervical screening and childhood immunisation programme. The practice had an action plan to improve uptake and data provided by the practice demonstrated an increase in the uptake of both cervical screening and childhood immunisations.
  • At the time of the inspection we did not see plans to upgrade the IT system had progressed since the last inspection. However, following our inspection the provider sent supporting evidence which demonstrated a formal action plan was in place with clear timescales.
  • Data we viewed during our first on-site visit did not provide assurance that systems in place to assure the quality of patient information including clinical data, such as read codes and diseases registers was effective. However, during our second on-site visit as part of this inspection, we saw no evidence that this had impacted on patients care and treatment.
  • During our fist on-site visit as part of this inspection, we found that there was no clear audit trail to demonstrate actions taken in response to abnormal test results. Following our inspection, the provider made changes to how actions and requests were being documented.
  • Vaccinations records were maintained in line with Public Health England (PHE) guidance for clinical staff. However, we were not provided with evidence for non-clinical staff. Following our inspection, the provider submitted evidence demonstrating non-clinical staff had received vaccinations.
  • At the time of our first on-site visit, we did not see evidence that the provider actively engaged with key stakeholder to help improve the service and deliver high quality and sustainable care. Following our first on-site visit as part of this inspection, the provider submitted evidence demonstrating engagement and the development of an action plan to improve identified areas. The provider sent further evidence following our on-site visit confirming the upgrade of the IT infrastructure had been completed in line with the practice action plan.

We rated the practice as requires improvement for providing effective services because:

  • Data over time indicated that actions taken to improve the uptake of national screening programmes and childhood immunisation had a slight impact; however, uptake rates continually remained below local and national averages.

The areas where the provider should make improvements are:

  • Continue taking action to improve the uptake of childhood immunisation as well as national screening programmes such as cervical, bowel and breast cancer screening.
  • Continue taking action in line with the practice action plan to improve patient satisfaction in relation to access.
  • Take action to implement and embed clear governance arrangements to enable effective management of historical patient information which does not hinder data quality.
  • Ensure upgrades to the IT infrastructure is well embedded.

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

25 November 2019

During a routine inspection

We carried out an announced comprehensive inspection at Naseby Medical Centre on 25 November 2019 as part of our inspection programme.

At the last inspection in August 2016 we rated the practice as good overall; however, requires improvement in responsive key question because:

  • Feedback from patients reported that access to appointments was not always available quickly, although urgent appointments were usually available the same day. The practice had developed an action plan to improve access, some of which had been implemented.
  • The uptake of national screening such as cervical, bowel and breast cancer screening was below local and national averages.

We carried out an announced desk-based focused inspection on 25 August 2017 to confirm that the practice had carried out their plan to make improvements in relation to patient satisfaction, availability of non-urgent appointments and uptake of health screenings. As a result of our findings we rated the practice as good for responsive services.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at all five key questions.

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 have rated this practice as requires improvement overall and requires improvement for population groups, except for older people, those whose circumstances make them vulnerable and people experiencing poor mental health (including people dementia) population group which we rated as good.

We rated the practice as requires improvement for providing safe, effective and well-led services because:

We found that:

  • The practice provided care in a way that mainly kept patients safe and protected them from avoidable harm.
  • Training records for clinical staff who were not directly employed by the practice did not demonstrate they were up to date with child safeguarding training. There were limited evidence of discussions with external health care professionals and the practice did not operate an effective system to evidence that all required recruitment checks were being carried out routinely. Following our inspection, the proactive provided evidence of completed safeguarding update training as well as engagement with external health care professionals.
  • Patients received effective care and treatment that mainly met their needs. However; there were areas where clinical outcomes and screening rates were significantly below national averages or targets. The practice demonstrated awareness of this and were taking action to improve patient outcomes including carrying out surveys to further identify root causes. They had developed action plans to improve uptake. However, these actions needed time to be embedded and reviewed to establish impact. Following our inspection, the provider supplied data which showed slight increases in the uptake of cancer screening.
  • The governance arrangements for managing the oversight of training and employment checks were not consistently applied. Documents such as some training records were obtained during the progress of our inspection, as well as induction check lists and reference checks which were provided following our inspection.

We rated the practice as good for providing caring and responsive services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The 2019 national GP survey showed areas where patient satisfaction was above local and national averages as well as areas where satisfaction had improved since the 2018 national GP patient survey. The practice internal 2019 GP patient survey also showed positive patient satisfaction.
  • The practice had an active patient participation group (PPG) and developed an action plan to further improve patient satisfaction in areas identified as areas for improvement.
  • The practice organised and delivered services to meet patients’ needs. The 2019 national GP patient survey showed patients satisfaction with access to care and treatment in a timely way had improved since the 2018 survey.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue taking action to improve the uptake of childhood immunisation as well as national screening programmes such as cervical, bowel and breast cancer screening.
  • Continue taking action in line with the practice action plan to improve patient satisfaction.
  • Take action to promoting the formal complaints process, improve patients access to the procedure.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

25 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Naseby Medical Centre on 19 May 2016. The overall rating for the practice was good; however, the practice was rated as requires improvement for providing responsive services. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Naseby Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced desk-based focused inspection carried out on 25 August 2017 to confirm that the practice had carried out their plan to make improvements in relation to patient satisfaction, availability of non-urgent appointments and uptake of health screenings and reviews that we identified in our previous inspection on 19 May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice continues to be rated as good.

Our key findings were as follows:

  • Since the previous inspection, the practice analysed the national patient survey result and developed an action plan. To improve patient satisfaction the practice employed a full time GP to increase appointment access, a new phone system was introduced and better use of online services were made.

  • As a result, data from the July 2017 national GP patient survey showed patient satisfaction had improved in most areas. Unverified data from internal surveys carried out by the practice also showed improvements.

  • Previously the practice uptake of national screening such as bowel and breast cancer was below local and national averages.

  • Members of the management team we spoke with explained that following a survey carried out in February 2017 to assess reasons for low uptake, the practice identified a number of barriers. For example, misunderstanding regarding the purpose of screening, literacy barriers and language barriers as well as cultural and religious reasons. As a result, greater awareness of the benefits of screening was discussed with patients. Alerts were added to patient notes which prompted clinicians to opportunistically provide health promotion and advice during appointments.

  • More effective systems for following up patients who missed screening appointments were introduced and reception staff were able to communicate with patients in various languages.

  • Data from the 2015/16 Quality and Outcomes Framework (QOF) showed that uptake rates for bowel cancer screening had declined; however breast screening slightly improved. Staff explained that they were aware of their performance and continued to educate patients on the benefits of screening. GPs were also engaging with local cancer intelligence networks to improve online literature in various languages.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Naseby Medical Centre on 19 May 2016. Overall the practice is rated as good.

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

  • Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients we spoke with told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • We saw evidence to demonstrate that the practice had carried out an analysis of its patient population profile and developed targeted services. For example by offering more in-house services such as focussed diabetes care or ECG monitoring.
  • We saw that the practice was proactive in improving patient outcomes where identified although improvements were not yet seen in the current data.
  • Patients did not always find it easy to make an appointment although urgent appointments were usually available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had carried out clinical audits and repeat audits to improve and maintain patient outcomes.
  • Information about services and how to complain was available in the waiting area and complaints information also found in the practice leaflet. Although the practice did not have any written complaints, we saw that verbal complaints were being logged on order to identify any trends.
  • There was a clear leadership structure and staff felt supported by management. The practice had sought feedback from staff and patients.

The areas where the provider should make improvement are:

  • Explore areas for improvement in the areas of lower patient satisfaction in the national patient survey.
  • Progress steps taken to improve the availability of non-urgent appointments and reduce appointment waiting times.
  • Continue with efforts to make and maintain improvements in the management and monitoring of outcomes for patients. For example, increasing uptake rates of health screening and reviews.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice