Background to this inspection
Updated
14 January 2019
Dr Abul Kalam Mohammed Raziur Rahman also known as Marshall Street Surgery provides primary medical services to approximately 1,800 patients within the local community. The practice is located in a converted residential property with consultation rooms on the ground floor and the first floor.
The provider is a male GP and there are two long term locum GPs (one female and one male). The nursing team consists of an advanced nurse practitioner who provide up to four sessions a week and a practice nurse who provides two sessions per week. The practice manager is also the business manager and is supported by a team of four administrative staff.
The practice holds a General Medical Services (GMS) contract with NHS England. The GMS contract allows the practice to deliver primary care services to the local communities. The practice provides GP services commissioned by NHS Sandwell and West Birmingham Clinical Commissioning Group (CCG). A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services.
The practice is situated in an area with high levels of deprivation with a score of level one. Level one represents the most deprived areas and level 10, the least deprived. The practice has a higher than average age practice population aged 18 years and under compared to the local and national average.
The main practice is open from 8am to 6.30pm Monday to Friday, with appointments available between 9am to 11.30am and 4pm to 6.30pm. Extended hours opening is 6.30pm to 8pm Mondays to Fridays, 9am to 12pm Saturdays and 9am to 11.30am Sundays as part of the local GP federation extended opening hours initiative.
The practice has opted out of providing out-of-hours services to their own patients. This service is provided by an external out-of-hours service provider when closed.
Updated
14 January 2019
This practice is rated as inadequate overall.
(Previous inspection rating March 2018 – Inadequate overall)
The key questions are rated as:
Are services safe? – Inadequate
Are services effective? – Inadequate
Are services caring? – Requires improvement
Are services responsive? – Requires improvement
Are services well-led? - Inadequate
We carried out an announced comprehensive inspection at Dr Abul Kalam Mohammed Raziur Rahman on 21 March 2018. Breaches of legal requirements were found and after the inspection we issued requirement notices for Regulation 17: Good governance and Regulation18 Staffing HSCA (RA) Regulations 2014. The service was placed into special measures.
The previous inspection reports for the service can be found by selecting the ‘all reports’ link for Dr Abul Kalam Mohammed Raziur Rahman on our website at www.cqc.org.uk.
This inspection was an announced comprehensive inspection carried out on 7 November 2018. The purpose of the inspection was to confirm if the service had made sufficient improvements and be removed from special measures
At this inspection we found:
- There were some systems and processes in place to keep people safe such as the appropriate and safe use of medicines and safeguarding procedures. However, not all risks had been assessed and managed effectively. The system for identifying and managing significant events was not robust in order to learn and improve the service.
- At the time of the inspection verified data showed that the practice was below local and national averages for a number of Quality Outcome Framework (QOF) indicators such as diabetes and asthma reviews. In addition, the practice was below local and national averages for cervical screening, breast and bowel cancer screening and cancer detection rates.
- Patient feedback from the inspection was overall positive. However, results from the national GP patient survey showed that the practice achievement was below local and national averages for health care professionals showing care and concern. The practice had identified insufficient number of carers based on the practice list size. Confidentiality in consultation rooms was not maintained.
- Patients did not find the appointment system easy to use and were not always satisfied with the type of appointment offered.
- The complaints system was not robust and did not ensure complaints were recorded and responded to effectively.
- There was a lack of leadership oversight and an effective governance framework to monitor the quality and safety of the service provided.
- Systems and processes were not always embedded to ensure risks were assessed and managed. This resulted in gaps and inconsistencies in the delivery and quality of the service.
The areas where the provider must make improvements as they are in breach of regulations are
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
This service was placed in special measures in March 2018. During this inspection, we identified that insufficient improvements had been made such that there remains a rating of inadequate for effective and well led. In addition, the practice is now rated inadequate for safe and requires improvement for caring and responsive. We have issued a warning notice to the provider for a breach in Regulation 17: Good governance and HSCA (RA) Regulations 2014.
I am extending the period of special measure for a further six months. 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 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.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice