Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Beeches Medical Centre on 22nd September 2015.

Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from risk of abuse.
• There were appropriate systems in place to reduce risks to patient safety, for example, infection control procedures and the management of medication. However, the recruitment records needed improvement and an up to date fire risk assessment needed to be made available.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.

• Patients were very positive about the care they received from the practice. They commented that they were treated with respect and dignity and that staff were caring, supportive and helpful.

• Services were planned and delivered to take into account the needs of different patient groups.

• Access to the service was monitored to ensure it met the needs of patients. Patients reported satisfaction with opening hours and said they were generally able to get an appointment when one was needed.

• The practice sought patient views about improvements that could be made to the service and acted on patient feedback. Information about how to complain was available.

• There were systems in place to monitor and improve quality and identify risk.

We saw an area of outstanding practice:

• The practice provided a service to homeless patients and had set up a system to contact homeless patients and ensure any hospital correspondence was sent to the practice.

However there were areas where the provider should make improvements.

Importantly the provider should:

• Demonstrate that they have obtained satisfactory information about any physical or mental health conditions which are relevant to the duties to be performed by staff.
• Ensure that an up to date fire risk assessment is made available.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 22 September 2015 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Beeches Medical Centre on 5 June 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

Previously we carried out an announced comprehensive inspection at The Beeches Medical Centre on 22 September 2015. The overall rating for the practice was good. The full comprehensive report on The Beeches Medical Centre can be found by selecting the ‘all reports’ link for on our website at www.cqc.org.uk.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• We saw some staff personal files did not contain evidence that all recruitment checks had been undertaken prior to employment. Following the inspection this evidence was provided.
• The last legionella risk assessment had been carried out on 13/8/15 (legionella is a term for a particular bacterium which can contaminate water systems in buildings).
• The gas and electrical safety certificate were dated 30/1/12. Evidence could not be provided of up to date certificates.
• A fire risk assessment had been undertaken in May 2018. The recommendations made in the report had not been actioned.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patient feedback on the care and treatment delivered by all staff was overwhelmingly positive.
• The practice sought patient views about improvements that could be made to the service; including having an active patient participation group (PPG) and acted, where possible, on feedback.
• Staff worked well together as a team, knew their patients well and all felt supported to carry out their roles.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas the provider must make improvements as they are in breach of regulation are:

• Ensure the premises are safe for their intended use.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice