Archived: Belsize Priory Medical Practice

We carried out an announced comprehensive inspection at Belsize Priory Medical Practice between 6th -8th September 2021. Overall, the practice is rated as requires improvement.

Why we carried out this inspection

We carried out an inspection to follow up on the previous inspection carried out in January 2019 where the practice received a requires improvement rating for the responsive domain. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Belsize Priory Medical Practice on our website at www.cqc.org.uk.

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 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 requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• We had concerns regarding the actioning of a drug safety alert, the cleanliness of the public toilets, the lack of posters stating what to do in the event of a sharp’s injury and safe disposal of sharps bins.

We rated the practice as requires improvement for providing effective services because:

• The practice’s uptake for childhood immunisation was below the national targets.

• The practice’s uptake for cervical screening was below the national targets.

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We re-rated the practice as good for providing responsive services because:

• We were now satisfied the practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing well-led services because:

• We were not assured there was appropriate processes in place for actioning all drug safety alerts; disposing of sharps bins; and to maintain standards of hygiene appropriate for the purposes for which the premises were being used.

Population Groups

• We rated older people and people whose circumstances may make them vulnerable as good.

• We rated people with long-term conditions as good.

• We rated families, children and young people as requires improvement because the practice has not met the WHO based national target of 95% (the recommended standard for achieving herd immunity) for five of five childhood immunisation uptake indicators.

• We rated working age people as requires improvement as the practice had not met the 80% national uptake target for cervical screening.

• We rated people experiencing poor mental health (including people with dementia) as good.

We found two breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
• Maintain appropriate standards of hygiene for premises and equipment (Please see the specific details on action required at the end of this report).

The provider should:

• Continue with efforts to improve the uptake of cervical screening and childhood immunisations.
• Consider increasing nursing staff and/or nursing working hours.
• Ensure sharps bins are disposed and replaced as per best practice guidelines.
• Ensure sharps injury posters are displayed in all consultation rooms.

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