The Care Quality Commission
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  • GP practice

Bellevue Medical Practice

Overall: Requires improvement read more about inspection ratings

6 Bellevue, Edgbaston, Birmingham, West Midlands, B5 7LX (0121) 728 8540

Provided and run by:
Modality Partnership

All Inspections

25 August 2022

During a routine inspection

We carried out an announced comprehensive at Bellevue Medical Practice on 25 August 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led – requires improvement

Following our previous inspection on 22 January 2020, the practice was rated requires improvement overall and for all key questions, except for the safe, caring and well led questions where the practice was rated as good.

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

Why we carried out this inspection

We carried out this inspection to follow up on the previous rating of requires improvement.

How we carried out the inspection/review

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

This included:

  • Conducting clinical 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:

  • During the remote review of the clinical system we found the management of patients’ medicines and monitoring of some patients’ conditions was not always effective.
  • Some patients on high risk medicines had not received the appropriate monitoring.
  • 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 had implemented a range of initiatives to provide care to patients who needed extra support. For example: vaccination programme for homeless people and a vulnerable patient project to ensure patients received the appropriate care.
  • There was a strong emphasis on learning and sharing outcomes with the whole team to promote best practice.
  • There was continuous commitment to patients and external stakeholders to share information, ideas and improvements. This included an audit programme to drive quality improvement.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • There was emphasis on staff wellbeing, and this was demonstrated through discussions with staff and evidence of appraisals.
  • Risk management processes were in place and we found assessments of risks had been completed. These included fire safety and health and safety. This ensured that risks had been considered to ensure the safety of staff and patients and to mitigate any future risks

We found breaches of regulations. The provider must:

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

The provider should:

  • Continue to encourage patients to attend for immunisations and cervical screening.

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

22 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Bellevue Medical Practice on 22 January 2020 to follow up on breaches of regulation we found during our inspection of the practice in April 2019.

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 the practice as Requires improvement overall and for providing Effective and Responsive services. We have rated all population groups as Requires improvement. This is because we found the difficulties patients experienced with telephone access and appointment availability affected all population groups.

We found that:

  • Not all patients received effective care and treatment that met their needs. Although the practice had reviewed systems to improve the management of patients not attending the practice for children’s immunisations and cervical cancer screening, the practice could not demonstrate they had fully explored all the barriers to patients not attending for their appointments.
  • Published data for patients with long term conditions and Mental health conditions showed that patients were not always receiving effective care and treatment.
  • The practice had made changes since the last inspection to improve telephone and appointment access. Data the practice gave us showed that patient satisfaction was improving, and data regarding call times showed that the amount of time patients were waiting to have the phone answered had reduced. However, patient feedback during the inspection, indicated that patients were still experiencing difficulties accessing the practice and the practice could not demonstrate that changes they had implemented had resulted in significant improvements in patient satisfaction.

We have rated this practice as Good for providing Safe, Caring and Well-led services.

We found that:

  • The practice had responded appropriately to our concerns from the last inspection and reviewed systems and processes to ensure that quality of care was being monitored and resources more effectively managed.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • We saw that staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had provided clinical and non-clinical staff with training where gaps in performance had been identified.
  • The practice had re-organised services to better meet patients’ needs.
  • 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:

  • Improve the incident reporting arrangements to enable a more accurate picture of incidents to be presented to the senior management team.
  • Continue to explore alternatives to increase uptake with children’s immunisation and cancer screening.
  • Continue to improve systems to monitor patient satisfaction information and continue to take appropriate action to be responsive to patients’ needs.

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

30 April 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at Bellevue Medical Practice on 30 April 2019 in response to concerns we had received regarding prescription management and telephone and appointment access. As part of this inspection we also visited the practice’s branch surgery; Modality Attwood Green.

The practice was previously rated as good overall with outstanding for providing responsive services. The previous reports for this practice can be found on our website www.cqc.org.uk.

During this inspection in April 2019 we only looked at how effective, responsive and well-led services were. Therefore, the ratings for safe and caring remain unchanged.

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 Requires improvement for providing effective and responsive services and Good for providing well-led services. We have rated all population groups as Requires improvement. This is because we found the difficulties patients experienced with telephone access and appointment availability affected all population groups.

We found that:

  • The practice had experienced significant challenges in the 12 months leading up to our inspection which had impacted on their ability to provide effective and responsive services.
  • Published data indicated the practice was not achieving targets for childhood immunisations, cervical screening and COPD reviews.
  • Results from the 2018 national patient survey showed patient satisfaction with telephone access was significantly below local and national averages.
  • The clinical leadership team were experienced, aware of the challenges facing the practice and had made some changes to the way they organised and delivered services to address challenges. However, they were not able to demonstrate if the changes had resulted in improved outcomes and satisfaction for patients.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • The practice should continue to monitor patient satisfaction information and take appropriate action to be responsive to patients’ needs.
  • The practice should review their arrangements for interpreting services.

  • The provider should continue to monitor uptake with cervical screening and explore alternative ways to improve uptake with screening.

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

29 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bellevue Medical Practice on 23 August 2016. The practice was rated requires improvement for providing safe services with an overall rating of good. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Bellevue Medical Practice on our website at www.cqc.org.uk.

This inspection was a follow up focused inspection carried out on 29 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 23 August 2016. This report covers our findings in relation to those requirements.

We found the practice had taken action to address areas where improvements were needed. The practice had made extensive changes which had resulted in significant improvements for providing safe services.

Our key findings were as follows:

  • Effective systems and processes had been implemented to ensure patients who were prescribed high risk medicines received monitoring in line with national guidance.

Janet Williamson

Deputy Chief Inspector of General Practice

23 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bellevue Medical Practice (known as Bellevue Medical Centre) on 23 August 2016. The overall rating for this service is good.

Our key findings across all the areas we inspected were as follows:

  • A system was in place for reporting and recording significant events, keeping these under review and sharing learning where this occurred.
  • Although processes and procedures were in place to keep patients safe these had not been followed for all patients prescribed high risk medicines.
  • The practice was aware of and provided services according to the needs of their patient population. This included transient patients such as students, asylum seekers and refugees.
  • Staff received regular training and skill updates to ensure they had the appropriate skills, knowledge and experience to deliver effective care and treatment.
  • Regular meetings and discussions were held with staff and multi-disciplinary teams to ensure patients received the best care and treatment in a coordinated way.
  • Patients told us they were treated with dignity and respect and that they were fully involved in decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand. Patients told us that they knew how to complain if they needed to.
  • The practice had an active Patient Participation Group (PPG). The PPG were proactive in representing patients and assisting the practice in making improvements to the services provided.
  • There was a clear leadership structure and staff told us they felt supported by management. The practice proactively sought feedback from patients, which it acted on. Staff appeared motivated to deliver high standards of care and there was evidence of team working throughout the practice.

We saw several areas of outstanding practice including:

  • Care and support was provided for patients at a local asylum dispersal centre. Specialist weekly clinics were provided at the centre to establish trust and maintain continuity among patients. At the time of the inspection there were 14 different communities using the centre.
  • The practice worked with a faith-based charity distributing meals to homeless people. They also engaged in a project to reduce avoidable deaths in homeless people by prescribing an injection that could save their lives in the event of an accidental overdose and also reduce hospital admissions.

The area where the provider must make improvements are:

  • Ensure that the systems and processes to address risks associated with high risk medicines are implemented to ensure patients’ safety at all times.

Janet Williamson  

Deputy Chief Inspector of General Practice