Dr Berni

We carried out an announced comprehensive inspection at Dr Berni on 20, 22 and 26 June 2023.

Overall, the practice is rated as inadequate.

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive - Good

Well-led – Requires improvement

This was the first comprehensive inspection of the practice since it was registered under a new legal entity.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities for inspecting newly registered services.

How we carried out the inspection

This inspection was carried out in a way that 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 arrangements for managing medicines did not always keep patients safe.
• Systems for managing historical safety alerts were not always effective.
• Care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways. Patients with long-term conditions were not always receiving appropriate monitoring and reviews. Patient consultation records were not always sufficiently detailed to demonstrate the actions taken and the rationale for care and treatment decisions.
• The delivery of high quality care is not assured by the governance arrangements.
• Arrangements for identifying, recording and managing risks were not fully effective.

• Staff dealt with patients with kindness and respect.
• Patient feedback about their involvement in decisions about their care and being treated with care and concern was positive.
• Patients were able to make appointments in a way that met their needs.
• Feedback from patients was being used to drive improvement.

We found 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 clinical governance in accordance with the fundamental standards of care.

Whilst not a breach of regulations the provider should:

• Take action to ensure patient records and registers are accurate in relation to all patients for whom there is a safeguarding concern.
• Take action to review the learning needs of members of the staff team and ensure training is planned to meet any identified needs.
• Implement a programme of effective clinical audit aimed at assessing and improving patient care and treatment.
• Ensure immunisation status checks have been obtained for all staff.
• Take action to increase the number of patients undergoing cancer screening.
• Introduce patient surveys and encourage patients to join a Patient Participation Group (PPG) to consult with patients and obtain their views and use this to drive improvement.

We wrote to the provider in June 2023 within a Section 31 letter, seeking evidence to assure us that immediate action was being taken to address the main issues that were identified by the inspection.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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