The Care Quality Commission (CQC) issued a report on the Cradley Heath practice, following an assessment between June 23 and July 11.
The GP surgery, located at 50 Barrs Road, Cradley Heath, serves 8,400 patients under a contract with NHS England.
The Office for Health Improvement and Disparities reports that the practice population is in the fourth decile for deprivation, meaning it is less deprived than some areas but still faces challenges.
Inspectors found that the practice had a learning culture and encouraged people to raise concerns.
Managers investigated incidents thoroughly, and most medicines were managed well.
However, the report identified that learning from incidents was not always shared with the whole team, and improvements were needed in acting on clinical alerts and reviews for people on high risk medicines.
Infection control processes also needed strengthening.
There were enough staff with the right skills, but some had carried out clinical assessments without the appropriate qualifications or supervision.
Systems for managing long-term conditions needed improvement to ensure people received the right care and treatment.
Patients were treated with kindness and compassion, and staff protected their privacy and dignity.
The service was easy to access, and people were involved in decisions about their care.
The practice worked to reduce health inequalities and eliminate discrimination.
Leadership at the practice was described as visible and supportive, but concerns were raised about the lack of clinical oversight and gaps in staff competencies and knowledge.
Governance arrangements were found to need strengthening to mitigate risks.
The practice was found to be in breach of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance). The provider has been asked for an action plan to address these concerns.
Recent surveys showed people were satisfied with the service, though some negative feedback on access was received.