Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bethesda Medical Centre on the 17 February 2015. A breach of the legal requirements was found. Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breach.

We undertook this focused inspection on the 2 November 2015, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Bethesda Medical Centre on our website at www.cqc.org.uk.

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 The Bethesda Medical Centre on the 17 February 2015. Overall the practice is rated as good.

We found the practice to be outstanding for providing effective services and good for providing caring, responsive and well-led services. It was also good for providing services to older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students) and for people experiencing poor mental health (including people with dementia). It was rated outstanding for people whose circumstances may make them vulnerable. The practice required improvement for providing safe services and the concerns which led to this rating applied to all population groups.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles, with the exception of some areas of training that had not been updated or undertaken, although further training needs had been identified and training planned.
• Recruitment procedures were not always used effectively when employing staff, as not all staff had undergone criminal records checks and the risks had not been assessed in relation to this.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they generally found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw some areas of outstanding practice:

• The practice worked in partnership with two other local practices to initiate a pilot scheme to provide an ‘out of hours’ on-call service with a paramedic practitioner, to respond, visit and support care home residents, who became unwell. The scheme had been developed to avoid unnecessary visits to the local hospital accident and emergency department. The latest data indicated that over a twelve week period, of the residents seen by the paramedic, 95% had remained at home, rather than being transferred to hospital by ambulance.

• The practice was located in an area of high deprivation and supported a range of patients with complex needs, including disadvantaged families who lived in vulnerable circumstances. A GP from the practice was involved in ‘street work’ activities with local support groups, including a ‘task force’ partnership. This involved approaching local families on a ‘one-to-one’ basis to promote health care services, many of whom had not registered with a GP. The group had received an ‘innovation collaboration award’ in recognition of their achievements in reaching out to vulnerable people in the local community, particularly those experiencing mental health problems.
• The practice had arranged an ‘outreach day’ at a local hotel to offer support to people who found it difficult to access GP services, and were sign-posted to other agencies and services who could help support their needs. The practice had registered many patients at the event and there was a particular focus on children who lived in vulnerable circumstances, in promoting childhood immunisations, as well as family planning and follow-up health care provision at the practice.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider MUST:

• Review the arrangements for DBS checks for administration staff who undertake chaperone duties.

Also, the provider SHOULD:

• Review the staff training requirements in relation to chaperone duties, the Mental Capacity Act 2005 and infection control.
• Review the processes for assessing the risks associated with legionella.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about The Bethesda Medical Centre on 11 June 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.