Blackheath Medical Centre

We carried out an announced inspection at Blackheath Medical Centre on 10 May 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

The practice was rated previously under its previous provider Dr Bennett Quinn. Dr Bennett Quinn was rated good overall and good for all key questions at its last inspection in July 2016. Blackheath Medical Centre was registered in 2019 and has not been inspected since this registration.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Blackheath Medical Centre on our website at www.cqc.org.uk.

Blackheath Medical Centre is registered with the Care Quality Commission (CQC) to provide the following regulated activities:

Diagnostic and screening procedures

Maternity and midwifery services

Treatment of disease, disorder or injury

Dr Bennett Quinn is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run .

Why we carried out this inspection

This inspection was a planned comprehensive inspection and carried out as part of our inspection programme.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit

Our findings

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

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Clinicians assessed patients according to appropriate guidance, legislation and standards and delivered care and treatment in line with current evidence-based guidance.
• There were sufficient staff who were suitably qualified and trained.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice understood its patient population and adjusted how it delivered services to meet the needs of its patients. It also did this specifically to adjust to situations during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There was an effective governance framework in place in order to gain feedback and to assess, monitor and improve the quality of the services provided.
• The provider was aware of the requirements of the Duty of Candour.

Whilst we found no breaches of regulations, the provider should:

• Document stock control of vaccines.
• Implement a process to review ‘do not attempt cardio pulmonary resuscitation’ (DNACPR) directive forms so they are completed and accessible to those who need them.
• Update the information on the practice website that is available to patients. In particular, how to make a complaint, translation services and information about support services for patients and their carers.
• Implement a written complaints information leaflet for patients/people to read and take away with them.
• Consider developing and documenting a formal strategy and business plan for service improvement and development and against which progress is measured.
• Capture actions taken in relation to risk assessments which are fully documented and reviewed for Legionella, security of the premises and paper records storage.

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