Billet Lane Medical Practice

We carried out an announced comprehensive inspection) at Billet Lane Medical Practice on 5, 12 and 20 July 2023. Overall, the practice is rated as requires improvement.

Safe - Requires Improvement.

Effective - requires improvement.

Caring - good.

Responsive - requires improvement.

Well-led - requires improvement.

Following our previous inspection on 27 July 2022, the practice was rated requires improvement overall and for the key questions safe, effective, responsive, and well-led.

The full reports for previous inspections can be found by selecting the 'all reports' link for Billet Lane Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up breaches of regulations 12,17 and 18 of the Health and Social Care Act 2008 from a previous inspection.

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.
• 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.
• 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 had a list of approximately 3,500 patients, the premises were limited and there was a small staff team, which had meant that informal systems had developed. Therefore, the governance systems in place for recruitment, patient referrals, and the safe monitoring of medicines, were not always robust and effective.
• The practice did not always have effective arrangements in place for managing risk regarding emergency medicines, and safety alerts.
• The practice had made some improvements following the previous inspection in July 2022 in staff training and the introduction of policies and procedures. However, further work was required to ensure all policies reflected staff practices.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The GP Patient survey results for the patient's access to the service were below national average.
• Clinical searches found patients receiving high-risk medicines, such as methotrexate, leflunomide and azathioprine potassium-sparing diuretic received appropriate monitoring.
• Staff were positive about the working at the service.
• The overall management of training had improved.
• The practice had made improvements to some of the policies and procedures.
• The system for the management of infection management and control was effective.
• The systems for the management of risk in the premises was effective.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Improve and formalise the monitoring of the children's safeguarding register.
• Take action to record the reviews of significant events at clinical meetings and complete a significant event log.
• Continue to improve staff uptake of training and the practices assurance of staff competencies for their roles.
• Improve schedule of clinical audits to monitor and improve patient's clinical care. demonstrate a quality service.

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 Health Care