Belvedere Medical Centre

At the last inspection on 17 September 2015 the practice was rated as good for each of the key questions and was rated as good overall.

We carried out this inspection at Belvedere Medical Centre following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection looked at the following key questions Safe, Effective, Caring, Responsive and Well-Led.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We rated the practice as good for providing safe services because:

• The practice did not always have clear systems and processes to keep patients safe.
• The practice had systems in place to manage significant events and medicines and safety alerts. However, there was limited evidence of what they did to monitor the implementation of medicines and safety alerts. There was limited evidence that actions were recorded on the safety alert monitoring log.
• The practice had appropriate systems in place for the safe management of medicines.
• The practice learned and made improvements when things went wrong.

We rated the practice as good for providing effective services because:

• Care and treatment of patients was appropriate and met their needs and preferences.
• Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the minimum 90% target for three of four childhood immunisation uptake indicators. Following our inspection, the practice sent us 2019/20 CHIS performance figures for three of the four childhood immunisation uptake indicators published by Public Health England (PHE). The practice had achieved the minimum target in all three areas (for two-year olds).
• There was evidence of improvements made through quality improvement The practice monitored the outcomes of care and treatment.
• The practice was able to show that staff had the skills, knowledge and experience to carry out their roles.
• The practice was able to show that it always obtained consent to care and treatment.
• Some performance data was significantly below local and national averages. For example, performance indicators for mental health patients showed care and treatment had not always ensured their needs were met. Following our inspection, the practice sent us their QOF report for Mental Health which showed performance from April 2019 to January 2020 had improved.

At this inspection we inspected all six population groups. We rated all population groups as good in effective.

We rated the practice as good for providing caring and responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The practice monitored patient satisfaction and they had identified themes in patient feedback. The practice had worked with the PPG to conduct a patient survey which was completed in October 2019.

We rated the practice as good for providing well-led services because:

• Leaders could show they had the capacity and skills to deliver high quality, sustainable care. Leaders had worked hard to stabilise the practice following the closure of a local practice and the influx of around 6,600 new patients.
• The practice had a clear vision, which was supported by a credible strategy.
• The practice culture supported high quality sustainable care.
• The overall governance arrangements were effective.
• The practice had clear processes for managing risks, issues and performance. However, risks management in relation to patient safety required improvement.
• We saw evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider should make improvements are:

• Continue to improve uptake of childhood immunisations and cervical screening.

• Review the staff vaccination policy to ensure it is maintained in line with current Public Health England (PHE) guidance.

• Continue to monitor patient satisfaction with telephone access, and take further action if necessary.
• Continue to ensure policies and procedures are followed; for example the safety alert protocol.
• Continue to monitor the number of carers on the register.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care