The Care Quality Commission
  • Doctor
  • GP practice

Belgrave Medical Centre

Overall: Good read more about inspection ratings

22 Asline Road, Sheffield, S2 4UJ (0114) 255 4498

Provided and run by:
Dr Gonapragasan Subramoney Chetty

Important: The provider of this service changed - see old profile

All Inspections

17 and 23 May 2023

During an inspection looking at part of the service

We carried out an announced comprehensive at Belgrave Medical Centre (also known as The Matthews Practice) on 17 and 23 May 2023. Overall, the practice is rated good. The practice had made improvements to the management of long term conditions. However, attainment in relation to childhood immunisations and cervical screening is still lower than target rates and had not improved since our last inspection.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good`

Following our previous inspection on 17 and 21 September 2021, the practice was rated good overall and for safe, caring, responsive and well led services. The practice was rated requires improvement for effective services.

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

Why we carried out this inspection

We carried out this inspection to follow up on shoulds identified from a previous inspection in September 2021:

  • Continue to improve the uptake of childhood immunisations and cervical cancer screening.
  • Lower than average attainment in relation to the management of some long term conditions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing and face to face.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • Reviewing staff feedback forms.
  • Reviewing PPG feedback forms.
  • Speaking with patients.
  • 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 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way. The practice were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to people who use services. For example a diabetes support group and a menopause initiative.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Leaders had an inspiring shared purpose, and strove to deliver and motivate staff to succeed.

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

  • Continue with plans to improve childhood immunisations and uptake of national screening programmes.
  • Implement and embed systems for monitoring the effectiveness of the care, treatment and support people with long term conditions receive.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

17 and 23 September 2021

During a routine inspection

We carried out an announced inspection at Belgrave Medical Centre on 17 and 24 September 2021. Overall, the practice is rated as good.

Safe - Good

Effective - Requires improvement

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection in January 2019, the practice was rated requires improvement overall and for being caring and responsive and good for safe, effective and well-led.

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

Why we carried out this inspection

This inspection was a comprehensive inspection on 17 and 24 September 2021 and looked at the shoulds from the previous January 2019 inspection:

  • Improve the cascade and management of safety alerts
  • Amend their staff vaccination protocol to include Varicella (chicken pox) and MMR (measles, mumps and rubella) in order to be in accordance with current Public Health England (PHE) guidance.
  • Improve patient access to services.
  • Review and improve patient satisfaction with regard to their involvement in decisions about their care and treatment and their access to appointments.

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 and for all population groups apart from working age people and families, children and young people which are rated as requires improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients 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.

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

  • Continue to improve the uptake of childhood immunisations and cervical cancer screening.
  • Support staff to work towards the relevant safeguarding children training level appropriate for their role.
  • Continue with plan to improve care form people with mental health issues.
  • Continue to address poor patient satisfaction regarding treating patients with care and concern.

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