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Two West Midlands GP Practices Placed into Special Measures

Two GP practices in the West Midlands run by the same GP have been rated as inadequate and placed in special measures by the independent health standards regulator.

The Care Quality Commission (CQC) inspected Bath Street Medical Centre in Dudley and Dr Mahbub's Surgery in Walsall last June, after receiving "information of concern" about both practices.

CQC inspectors substantiated the concerns, finding significant patient safety failures in a range of areas, including prescribing of medicines, gaps in information recorded in people's consultation records, and delays in actioning clinical referrals and referrals to secondary services.

Following the CQC inspections, the overall rating for both practices dropped from 'good' to 'inadequate', while the ratings for being safe, effective, and responsive were downgraded from 'good' to 'inadequate'. The rating for caring dropped from 'good' to 'requires improvement'.

Due to the seriousness of the issues identified during the inspections, the Black Country Integrated Care Board (ICB), which commissions GP services across the West Midlands, arranged a caretaker provider to run GP services from both practices. All patients received a communication about this change in July.

The GP principal of both practices, Dr Selim Mahbub, is not providing care at this time, and both services will be kept under close review and reinspected, the CQC said. If sufficient improvements are not made, further enforcement action will be taken, which could include closure.

Multiple Findings of Concern

In both GP services, CQC inspectors found multiple issues with patient care and safety. These included:

  • Patients' needs not always being assessed, and care and treatment not always delivered in line with standards and legislation.
  • Safeguarding registers had not been maintained appropriately and the information held was inaccurate.
  • A lack of oversight of staff carrying out clinical roles to ensure they were working within their competencies.
  • Significant concerns in the prescribing of medicines, and gaps in the information recorded in consultation records.
  • The practices were unable to demonstrate that incidents affecting the health, safety, and welfare of people using services were reported internally and shared with staff to promote learning and improvement

Lack of Oversight

Andy Brand, CQC deputy director of operation in the Midlands, said people weren't receiving the appropriate care and treatment they had a right to expect at Bath Street Medical Centre and Dr Mahbub's Surgery. "There was a lack of oversight from the provider, and they weren't aware of the issues both services faced. This led to a poor culture, where staff felt undervalued and unsupported, especially when they were understaffed. Also, we found some staff hadn't received the necessary training to be able to carry out their roles effectively." 

The lead GP was covering both practices, which resulted in delays issuing time-sensitive medicines for people, inspectors found. Also, each morning the provider was diverting calls from Dr Mahbub's Surgery to Bath Street Medical Centre. This increased the volume of calls, resulting in patients findings it difficult to get through to the practice.

Mr Brand said: "It was concerning that Bath Street didn't have an effective system to ensure abnormal test results were actioned in a timely way. This placed people at risk of having undiagnosed and untreated conditions.

"At Dr Mahbub's Surgery we found multiple fit notes left uncollected. One was issued last June but there was no record of the person being seen or requesting the fit note in the first place. We found another five which were uncollected and some expired last year. Also, there was no system in place for managing uncollected prescriptions which could put people at risk of harm."

Safety and Wellbeing of Patients "Remains Top Priority"

In a statement, Dr Mona Sidhu, medical director of primary care for the NHS Black Country ICB, said it was important that patients of the two practices continue to come forward for any care and support they need during this time.

She said: "We have been working closely with the CQC following concerns raised about the quality of care at Bath Street Medical Centre and Dr Mahbub's Surgery (Brace Street Health Centre), and we support the decision to suspend the contract with the GP partner whilst improvements are made.

"The safety and wellbeing of patients remains our top priority, and we are committed to ensuring patients continue to have access to primary care services."