• Doctor
  • GP practice

The Belgrave Medical Centre

Overall: Good read more about inspection ratings

13-13a, Pimlico Road, London, SW1W 8NB (020) 7730 7030

Provided and run by:
The Belgrave Medical Centre

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

All Inspections

During an assessment under our new approach

Date of Assessment: Remote clinical searches were carried out on 14 May 2026 and the site visit took place on 19 May 2026.

The Belgrave Medical Centre is a GP Practice registered as a partnership since its CQC registration in November 2021. It is currently rated as requires improvement overall, including in the safe and effective key questions, and inadequate in the well-led key question. A warning notice was served for the breach of regulation 17 at the last assessment in July 2023. This comprehensive assessment was undertaken because of the overall rating of requires improvement and to follow up on the warning notice issued for the breach of regulation related to good governance in 2023.

The Belgrave Medical Centre is a GP Practice that delivers General Medical Service (GMS) to approximately 11,169 patients in the London Borough of Westminster under a contract held with NHS England. The National General Practice Profile states that the population make up for this location is 64.2% White, 13.3% Asian, 7.9% Black, 6.1% Mixed and 8.6% other non-white ethnic groups.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

This service is no longer in breach of regulation because we found that considerable improvement had been made since the last assessment in 2023. There were no new breaches of regulation found during this assessment and what we found is as follows:

Safe: The previous assessment in 2023 found the service to be unsafe due to the concerns identified. However, at this assessment, we found that the service had taken action to mitigate the risks associated with those concerns. People and staff were kept safe and protected from harm and abuse. The practice recorded significant events and learning shared with the practice staff. Risks were understood and managed by the staff. The Infection Prevention and Control policy was specific to the practice and regular audits were completed. However, there were gaps in relevant staff training.

Effective: The previous assessment in 2023 found the service not to be effective due to the concerns identified. However, at this assessment, we found that the service had taken action to mitigate the risks associated with those concerns. People were involved in the assessment of their needs. Patients were invited for their health checks reviews. The practice delivered services in line with good practice. The practice worked with relevant stakeholders to achieve best outcomes for the patient population. Information was shared with the patients to ensure they made an informed decision about their health care needs. An action plan had been implemented to improve the uptake of cervical screening and childhood immunisations among patients identified as not engaging with these programmes.

Caring: People were treated with kindness and compassion by the clinical staff. The dignity and privacy of patients were respected. Staff felt valued and appreciated. Staff wellbeing was treated with the utmost importance by the service.

Responsive: People received services that were in line with the Equality Act. An interpreting service was made available to patients who needed it. Complaints were handled carefully and timely. People told us that they could access services easily at this location indicating an improvement since the last assessment in 2023.

Well-led: The previous assessment in 2023 found the service not to be well-led due to the concerns identified. However, at this assessment, we found that the service had taken action to mitigate the risks associated with those concerns. The leadership and the management of the practice operated an open-door policy and shared the vision of the practice with staff. The leadership and management had a clear understanding of equality, human rights and safe compassionate care. Members of staff understood their roles and responsibilities and felt supported. However, there was still need for more improvement in relation to governance and oversight of administrative tasks.

6 July 2023

During a routine inspection

We carried out an announced comprehensive inspection at The Belgrave Medical Centre on 6 July 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - inadequate

During the inspection process, the practice highlighted efforts they are making to improve outcomes and treatment for their population. These had only recently been implemented so we were unable to assess the impact of these improvements. As such, the ratings for this inspection have not been impacted. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.

Why we carried out this inspection

We carried out this inspection in response to concerns reported to us and because the new provider had yet to be rated since registration in November 2021. We reviewed all key questions as part of this 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 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 did not always provide care in a way that kept patients safe and protected them from avoidable harm as the practice did not have effective systems for the appropriate and safe use of medicines.
  • People with some long-term conditions did not receive effective care and treatment that met their needs.
  • Patients rated the practice in line with local and national averages for questions relating to the care they received.
  • Patients could access care and treatment in a timely way.
  • The overall governance arrangements were inadequate as we identified concerns which did not promote the delivery of high-quality, person-centred care.

We found a breach of regulations. The provider must:

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

The areas where the provider should make improvements are:

  • Take action to ensure the process of monitoring blank prescriptions is sustained.
  • Improve the risk assessment process to determine if staff are required to undertake a DBS check.
  • Improve managerial oversight of staff mandatory training.
  • Improve uptake of cervical screening for the benefit of eligible patients.
  • Take action to improve communication between senior leaders.
  • Continue to establish an active Patient Participation Group (PPG).

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