The Care Quality Commission
  • Doctor
  • GP practice

Brace Street Health Centre

Overall: Good read more about inspection ratings

63 Brace Street, Walsall, West Midlands, WS1 3PS (01922) 624605

Provided and run by:
Dr Anand Kumar Sinha and Dr Minaxi Verma

All Inspections

20 June 2023

During a routine inspection

We carried out an announced comprehensive inspection at Brace Street Health Centre on 20 June 2023. Overall, the practice is rated as good.

Safe - requires improvement

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 5 May 2022, the practice was rated requires improvement overall and for all key questions except the caring key question which was rated as good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Brace Street Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on the breaches of regulation from a previous inspection.

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:

  • Conducting clinical staff interviews using video conferencing.
  • 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.
  • Face to face interviews with staff.

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 had a system in place for the actioning of safety alerts, however this needed strengthening to ensure all alerts were acted on in a timely manner to mitigate risk.
  • The management of patients medicines required improvements to ensure the appropriate monitoring was in place.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Governance processes had been strengthened. Risk management processes were in place and we found assessments of risks had been completed. These included fire safety and health and safety. This ensured that risks had been considered to ensure the safety of staff and patients and to mitigate any future risks
  • Patients could access care and treatment in a timely way.
  • Staff were well supported and learning was encouraged.

We found a breach of regulation. The provider must:

  • Ensure that care and treatment is provided in a safe way

The provider should:

  • Continue to encourage patients to attending screening and immunisation appointments.

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

5 May 2022

During a routine inspection

We carried out an announced inspection at Brace Street Health Centre 5 May 2022. Overall, the practice is rated as Requires improvement.

We rated each key question as follows:

Safe - Requires Improvement.

Effective -Requires Improvement.

Caring – Good

Responsive - Requires Improvement.

Well-led - Requires Improvement.

Why we carried out this inspection

This inspection was a comprehensive inspection which included a site visit to:

  • Rate the service following registration as a new provider.

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out with the aim to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • 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 have rated this practice as Requires Improvement overall

We found that:

  • The practice did not have fully effective systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients on high risk medicines.
  • The practice was unable to demonstrate that it consistently acted on safety alerts.
  • There was an inconsistent approach to the management of patients care and treatment including those with long term conditions with a lack of effective clinical oversight.
  • The practice was below national averages for cancer screening and the uptake of childhood immunisation.
  • Comprehensive quality assurance systems were not in place to demonstrate the competency of staff undertaking advance clinical practice.
  • People were not always able to access care and treatment in a timely way. The results of the recent national GP survey showed the practice was below the local and national averages for questions relating to access.
  • The processes for managing quality and safety risks were not always supported by fully embedded assurance systems such as safeguarding and recruitment.
  • The system in place to assess and monitor the governance arrangements in place required strengthening.
  • Staff described a positive culture with practice wide learning encouraged and supported.
  • There was compassionate and inclusive leadership at all levels.

We found two breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • 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:

  • Develop comprehensive quality assurance systems to demonstrate the competency of staff undertaking extended roles.
  • Continue to monitor and take action to improve the uptake of cancer screening and childhood immunisation.
  • Review systems in place for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions to ensure they are consistently recorded and reviewed in line with relevant legislation.
  • Improve patients experience and access to the service by increasing choice and flexibility. Establish systems to obtain patient feedback on an ongoing basis.

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