Burnett Edgar Medical Centre

We carried out an announced comprehensive inspection at Burnett Edgar Medical Centre on 16 November 2018 as part of our inspection programme. We rated the practice as requires improvement for providing safe services and good overall.

The full comprehensive report on the November 2018 inspection can be found by selecting the ‘all reports’ link for Burnett Edgar Medical Centre on our website at www.cqc.org.uk.

At our inspection in November 2018 we rated the practice as requires improvement for providing safe services because:

• Records of staff training were incomplete, and some staff had not undertaken training according to practice policy.
• The practice clinical audit programme was in need of review to ensure it was appropriate for the needs of the practice.

We also indicated improvements should be made as follows:

• Perform an analysis of themes from significant events to look for trends;
• Include details of safeguarding procedures in the locum pack.

On 17 January 2020, we carried out a focused, desk-based inspection of the safe key question. We reviewed evidence submitted by the practice to confirm it had carried out the plan to meet the legal requirements in relation to the breaches in regulations identified in our previous inspection on 16 November 2018. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection, we found that the provider had satisfactorily addressed all legal requirements and suggestions for improvements.

We have rated this practice as good for providing safe services.

We found that:

• Adherence to practice policy and procedure in relation to staff training was improved. Staff and GPs had generally undertaken required annual training and there were comprehensive records of this in place.
• We saw evidence staff were appropriately trained for safeguarding patients and safeguarding information had been included in the GP locum pack.
• There was evidence of an audit programme appropriate to the needs of the practice.
• The management of significant events had improved, and we saw learning was shared routinely with staff.

Whilst we found no breaches of regulations, the provider should:

• Ensure all staff and GPs follow the practice protocol for undertaking annual practice mandatory training in all areas, including fire training.

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

This practice is rated as Good overall. (Previous rating November 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Burnett Edgar Medical Centre on 16 November 2018 as part of our inspection programme.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We saw an area of outstanding practice:

• Doctors at the practice worked closely with the Integrated Care Community (ICC) to set up a community-based support group for patients with neurological conditions called Café Neuro, and a Wellness Group which used yoga, healthy eating advice, and relaxation techniques involving Virtual Reality headsets to encourage patients to lower stress levels and improve their overall wellbeing.

However, we saw some areas where the practice must make improvements:

• Ensure systems and processes are operated effectively For details, please refer to the requirement notice at the end of the report.

We also saw some areas where the practice should make improvements:

• Perform an analysis of themes from significant events to look for trends;
• Include details of safeguarding procedures in the locum pack.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice