Letter from the Chief Inspector of General Practice

We first inspected Bearwood Medical Centre on 21 September 2016 as part of our comprehensive inspection programme. The overall rating for the practice was good; however we identified a breach in the responsive key question. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Bearwood Medical Centre on our website at www.cqc.org.uk. During the inspection we found the practice was in breach of legal requirements. The breaches related to reasonable adjustments that had not been made in line with the Equality Act 2010. Following the inspection the practice wrote to us to say what they would do to meet the regulations.

This inspection was an announced focused inspection carried out on 30 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall we found improvements had been made to the concerns raised at the previous inspection and as a result of the inspection findings the practice is now rated as good for the responsive key question and continued to be rated as good overall.

Our key findings across all the areas we inspected were as follows:

• Since the previous inspection the practice had completed an assessment to assess compliance with the Equality Act (2010). An action plan was in place and reasonable adjustments had been made.
• The practice had installed a hearing loop to support patients with hearing difficulties and alerts were added to patients’ records to advise all staff if patients needed extra support.
• Low level signage had been implemented to assist patients in wheelchairs.
• The practice had purchased chairs with arms to support patients with mobility difficulties.
• A doorbell had been fitted to alert the reception staff that a patient required assistance to enter the premises.
• At the previous inspection we were told that the practice was waiting for funding to make improvements to the premises and surrounding area to assist patients with mobility difficulties. At this inspection we found funding still had not been received, but we saw evidence to confirm the clinical commissioning group (CCG) were aware of the improvements required and the practice was part of a future strategy plan for funding.
• Since the last inspection, the practice had joined a group of general practices to set up access ‘hubs’ across the locality so patients could access appointments during the evening between 6.30pm and 8pm and on Saturday and Sunday mornings.

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Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bearwood Medical Centre on 21 September 2016.

Bearwood Medical Centre was previously inspected on 4 March 2015 and was rated as Requires Improvement. We found the provider to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The regulations breached were:

Regulation 17: Good governance. The practice did not have effective systems to idenitify, monitor and manage all risks within the practice.

. At this inspection we found the practice had made some improvements, but there were still outstanding actions to be completed.Overall the practice is rated as Good.

Our key findings across all the areas we inspected were as follows:

• Risk assessments had been completed since our previous inspection, but we found that effective reviews of managing patient safety were required. For example, boxes of hypodermic needles were stored in the corridor, accessible to the public.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. We saw improvements in the management of patients using NICE guidelines.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment and feedback from patients about their care was consistently positive.
• The practice had a range of policies in place, but they were in a generic format and had not been reviewed and made specific to the practice needs.
• At the previous inspection staff showed a lack of confidence in using the clinical system. We saw evidence to confirm that staff had received support and training and were now competent in using the clinical system.
• We saw that staff were friendly and helpful and treated patients with kindness and respect. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• At the previous inspection it was identified that the practice had not completed an audit to assess compliance with the Equality Act (2010), we found at this inspection that reasonable adjustments had still not been made The practice had no hearing loop and on speaking with staff it was difficult to confirm how patients with hearing difficulties were supported.
• The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result. The provider was aware of and complied with the requirements of the duty of candour.

The areas of practice where the provider must make improvements:

• The practice should continue to progress the funding to ensure that reasonable adjustments can be made in line with the Equality Act 2010.

In addition the areas of practice where the provider should make improvements:

• Review safety procedures and implement systems to assess, monitor and manage risks relating to the health, welfare and safety of patients.
• Review practice policies to ensure they are practice specific.
• Continue to act and review access to appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We first inspected Bearwood Medical Centre on 21 September 2016 as part of our comprehensive inspection programme. The overall rating for the practice was good; however we identified a breach in the responsive key question. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Bearwood Medical Centre on our website at www.cqc.org.uk. During the inspection we found the practice was in breach of legal requirements. The breaches related to reasonable adjustments that had not been made in line with the Equality Act 2010. Following the inspection the practice wrote to us to say what they would do to meet the regulations.

This inspection was an announced focused inspection carried out on 30 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall we found improvements had been made to the concerns raised at the previous inspection and as a result of the inspection findings the practice is now rated as good for the responsive key question and continued to be rated as good overall.

Our key findings across all the areas we inspected were as follows:

• Since the previous inspection the practice had completed an assessment to assess compliance with the Equality Act (2010). An action plan was in place and reasonable adjustments had been made.
• The practice had installed a hearing loop to support patients with hearing difficulties and alerts were added to patients’ records to advise all staff if patients needed extra support.
• Low level signage had been implemented to assist patients in wheelchairs.
• The practice had purchased chairs with arms to support patients with mobility difficulties.
• A doorbell had been fitted to alert the reception staff that a patient required assistance to enter the premises.
• At the previous inspection we were told that the practice was waiting for funding to make improvements to the premises and surrounding area to assist patients with mobility difficulties. At this inspection we found funding still had not been received, but we saw evidence to confirm the clinical commissioning group (CCG) were aware of the improvements required and the practice was part of a future strategy plan for funding.
• Since the last inspection, the practice had joined a group of general practices to set up access ‘hubs’ across the locality so patients could access appointments during the evening between 6.30pm and 8pm and on Saturday and Sunday mornings.

.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our previous inspection on 26 September 2013 we saw that the recruitment processes in place were not robust. We also identified that improvements were needed to the systems used at the practice for assessing and monitoring the quality of the service provided to patients. Following the inspection we asked the registered manager to send us an action plan setting out how they would address the identified issues. To date we have not received this document.

We saw that a fire risk assessment had been completed in November 2013. The risk assessment identified areas requiring urgent attention. We found that not all of the actions requiring immediate attention had been completed.

We looked at the recruitment process for one staff member who had been recruited by a newly appointed practice manager. We saw that improvements to the recruitment process were evident.

We visited the surgery to establish that the needs of people using the service were being met. On the day of the inspection we spoke with five staff members, the practice manager, assistant practice manager, associate GP, practice nurse and a receptionist. We also spoke with four patients who had arrived for their appointment. All the patients we spoke with were generally complimentary about the service.

We found that care and treatment was planned and delivered in a way that met patients’ needs and protected their rights. Patients were able to be involved in decisions about their treatment. Patients we spoke with told us they were happy with the level of care they had received.

Staff had received training in safeguarding children and vulnerable adults. They were aware of the appropriate agencies to refer safeguarding concerns to that ensured patients were protected from harm.

The provider did not have a robust recruitment system to ensure only appropriate people were employed.

The staff we spoke with said they had received training appropriate to their role. This supported staff to deliver care to an appropriate standard.

The provider did not have a robust system in place for monitoring the quality of service provision.