Archived: Bath Street Medical Centre

Updated 8 November 2023

Bath Street Medical Centre is located in Dudley at:

73 Bath Street
Sedgley
Dudley
DY3 1LS

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Black Country Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 2,900. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices called a Primary Care Network (PCN). This practice is part of the Sedgley, Coseley and Gornal PCN.

Information published by Public Health England shows that deprivation within the practice population group is ranked as level 4, with 1 being the most deprived and 10 being the least deprived. According to the latest available data, the ethnic make-up of the practice area is 85% White, 8% Asian, 3% Black, and 4% Mixed or Other.

The practice is run by a single handed GP (male). The clinical team includes 4 part time GP locums, a part time physician associate, a part time pharmacist, 2 part time practice nurses, and 2 part time healthcare assistants. The clinicians are supported by 2 part time practice managers and a team of reception/administration staff.

The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. Out of hours services are provided by NHS111.

Updated 8 November 2023

We carried out an unannounced comprehensive inspection at Bath Street Medical Centre on 19 June 2023. Overall, the practice is rated as inadequate.

We rated each key question as follows:

Safe - inadequate

Effective - inadequate

Caring - requires improvement.

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 21 January 2019, the practice was rated good overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bath Street Medical Centre 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 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 that safe systems or practices were in place or working effectively in relation to health and safety, medicines management, safeguarding, recruitment, or the management of risks to patients or staff.
• There was a lack of leadership oversight and the absence of comprehensive systems and processes to monitor the quality and effectiveness of the service and the care provided.
• Staff did not always have the information they needed to deliver safe care and treatment. For example, not all patients had health conditions clinically coded appropriately and the summary of their medical problems was not up to date.
• Safeguarding registers had not been maintained appropriately and the information held was inaccurate.
• There was a lack of 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 the gaps in the information recorded in patients’ consultation records. There was no systematic structured approach with effective clinical oversight of patient information including clinical data.
• The provider 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.
• There was no carers register in place and patients were not always given timely information regarding their treatment.
• 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 culture did not effectively support high quality sustainable care.
• The overall governance arrangements were ineffective. The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• There was limited evidence to demonstrate that the practice involved patients, staff or stakeholders in shaping the service.

We found 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.

The provider should:

• Implement a process to encourage patients to attend for cervical and breast cancer screening.
• Implement a carer’s register.
• Review hypnotic and psychotropic prescribing.

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