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Bentham Road Health Centre Good Also known as Cornerstone Healthcare

Reports


Review carried out on 17 January 2020

During an annual regulatory review

We reviewed the information available to us about Bentham Road Health Centre on 17 January 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 31 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bentham Road Health Centre on 13 October 2016. The overall rating for the practice was good, although the practice was rated as requires improvement for safety.

The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Bentham Road Health Centre on our website at www.cqc.org.uk.

This inspection was an announced desk based inspection carried out on 31 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 13 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for safe services, and overall the practice is rated as good.

Our key findings were as follows:

  • Portable electrical appliances were tested to ensure they were in good working order and safe to use.

  • Infection prevention and control audits were being carried out on a six-monthly basis.

  • An assessment of the fixed electrical appliances had been conducted.

  • A Legionella risk assessment had been carried out and there was evidence to demonstrate that water outlets were tested on a regular basis.

  • Patient specific directions (PSD) for the healthcare assistant to administer vaccinations were signed by the prescriber before the treatment was administered.

  • There were systems in place to monitor the stock of single use items to ensure they were within their expiry date and safe for use.

  • Systems were in place to disseminate patient safety alerts and manage significant events.

  • The practice business continuity plan was shared with staff so that they were aware of individual roles and responsibilities in the event of the plan being implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 13 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bentham Road Health Centre on 13 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. There was evidence of discussion and subsequent action but supporting records were not maintained in a consistent manner.
  • Risks to patients were assessed and managed. However, some supporting systems and processes were not implemented well enough to ensure patients were kept safe.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour and had developed a policy to support compliance with the duty.
  • The practice was a training practice and documented feedback trainees indicated training was provided to a high standard.

We saw several areas of outstanding practice including:

  • The practice had identified a number of common social issues faced by older patients and had organised and held regular events to assist patients to overcome these issues.

  • A Chaplain employed by the wider Cornerstone Healthcare Group regularly worked with and provided support to vulnerable practice patients and their families to overcome health and social issues and challenges.

The areas where the provider must make improvement are:

  • Undertake a comprehensive infection prevention and control audit.
  • Ensure electrical equipment testing is undertaken and supported by comprehensive, complete equipment and maintenance records.
  • Develop and implement a system to ensure single use clinical items are formally checked to ensure they remain fit for use.
  • Ensure patient specific directions are appropriately authorised before associated activity is completed.

There were areas of practice where the provider should make improvements:

  • Consider the need for comprehensive complaint and significant event registers to be maintained to support learning and improvement.

  • Complete the development and implementation of a comprehensive system for the distribution of safety alerts and recording associated actions.

  • Complete the planned review of the legionella risk assessment.

  • Consider improving communication of the practice business continuity management plan to ensure all staff are aware of the contents and responsibilities.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 5 February 2014

During a routine inspection

During our inspection we spoke with two people who had attended for appointments, four members of the Patient Participation Group (PPG), one GP, the practice manager, a practice nurse, a health care assistant, the site manager, the chaplain employed to work in the practice and two members of reception staff.

People told us they were fully involved in discussions and decisions about their treatment and said they were listened to by the doctors and nurses in the practice. Comments included, �The choices I had for my treatment were all discussed� and �Staff are nice; they listen to you�.

People were very satisfied with the way they were treated by staff. The comments they made to us included, �Staff are all totally caring and professional� and �Staff don�t look at you funny because of your age; they just look at what you are here for�.

The practice had policies in place in relation to safeguarding children and adults. Staff had undertaken appropriate training and were aware of the action to take should they have any concerns about people who attended the practice.

Staff told us they enjoyed working at the practice and felt supported by other members of the team. Comments included, �It�s wonderful to work here� and �We all care for each other and work well as a staff team�.

The provider had appropriate systems in place to monitor the quality of service provision. We found people's views had been taken into account in the way the service was provided.