Bethnal Green Health Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. Staff felt safe to raise concerns and incidents were investigated. However, people were not always protected through effective risk management. Managers had not ensured staff received regular training and appraisals to support the delivery of high-quality care. Staff did not always carry out patients’ blood tests and physical checks prior to a review or prescription being issued. The service was in breach of legal regulations relating to health and safety, staff training and recruitment and patient monitoring and adherence to clinical guidance. The provider acknowledged these findings and stated that key processes would be reviewed and reinforced following our feedback. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Inadequate.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff embedded a culture of openness and collaboration at all levels of the organisation. The practice had systems to learn from incidents and improve services. Staff felt able to raise safety concerns, investigated events, and shared learning to help embed best practice. The whole team discussed and learnt from clinical issues. The service held weekly clinical team meetings to discuss any cases of concern and we saw these meetings were recorded. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The service had a duty of candour policy in place. A member of the Patient Participation Group confirmed the provider took concerns seriously and acted to improve the service.

The service had systems in place to receive, share and act on safety alerts. We saw evidence of clinical audits in response to Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts. However, leaders could not demonstrate complete oversight regarding the management of patient safety alerts. For example, we identified 5 patients on a combination of prescribed medicines, who may have been affected by an MHRA alert. We could not find any record that these patients had been informed of the risks relating to prescribing outside national guidelines.

Staff made sure there was continuity of care, including when people moved between different services. The service had robust systems in place to ensure information was effectively shared across teams and agencies, enabling the delivery of safe, coordinated care. There was a system in place to ensure referrals to specialist services were documented and contained the required information. The practice had a process to safety-net newly diagnosed patients and record they had been booked for a GP consultation. Referrals and test results were managed promptly enabling the delivery of safe, coordinated care.

Communications from secondary care, such as discharge summaries, were processed efficiently to ensure continuity of care. However, where some patients were under the care of a hospital team, we found recording secondary care monitoring arrangements needed strengthening. The service had a new patient registration policy and there were systems in place for processing information relating to new patients.

The service had systems and processes in place to safeguard adults and children from abuse. Staff reviewed practice safeguarding registers for both children and adults. Staff ran regular safeguarding searches of patient records which looked for all registered patients whose records had a safeguarding code applied.

Safeguarding alerts were added to clinical records when relevant, enabling staff to identify concerns and respond appropriately, including working with partner agencies. All staff knew who the safeguarding lead was, how to escalate concerns, and how to act if they suspected a patient was at risk. However, training records we checked showed 2 members of staff had not completed safeguarding training appropriate to their roles. There was no record of completed Mental Capacity Act online training for 3 members of clinical staff which should be renewed every 3 years.

The safeguarding policy had been reviewed by the GP Partner in March 2026. The policy set out the process for raising and sending a safeguarding concern and included the name of the practice safeguarding lead. There were posters displayed with local safeguarding team contact details. There was a list of recommended safeguarding codes to ensure patients at risk could be identified by staff.

Staff we spoke with told us the service had a Was Not Brought (WNB) protocol and that they would always follow up on children and vulnerable adults who missed or did not attend at prearranged appointments. However, the GP Partner told us they had not yet carried out an annual audit of children who were not brought to appointments, or an audit of attendances at accident and emergency services to identify any patterns which may indicate neglect.

Staff had identified risks within the care environment, ensuring equipment, facilities, and technology supported delivery of safe care. The service was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff provided an example in which they dealt with a medical emergency (patient collapsing) in the practice. However, on the day of the site visit, managers could not show evidence of staff members completed basic life support training. There was no record of completed sepsis training for 3 members of staff.

The service operated an online consultation service to help triage patient queries and appointment requests. The service had a triage protocol with guidance for staff to identify and escalate risk to an appropriate clinician. The service had developed a GP hub supervisor role, to enable prompt prioritisation of patients with urgent clinical needs.

The service had processes to detect and control potential risks in the care environment. The facilities and premises were well-maintained, and the equipment used to deliver care and treatment was safe to use, stored securely, and calibrated correctly to support the delivery of safe and effective care.

The practice had a health and safety policy. The landlord of the building NHS Property Services (NHSP), had arranged health and safety risk assessments, including electrical, gas, and Legionella, which had been completed within the past 12 months. The provider told us that progress of remedial actions was reviewed regularly with the building managers. Leaders told us they had a practice risk register to monitor health and safety risks. During the inspection we reviewed the practice risk register but found this was not routinely used to document risks relating to health and safety. The risk register did not include action plans for managing all identified risks.

We found the premises were clean and tidy. Maintenance contracts were in place to ensure the premises were maintained to keep everyone safe. The service had a business continuity plan which was monitored and reviewed. Staff reported no concerns regarding health and safety arrangements.

The service had a recruitment policy, but recruitment checks were not consistently followed. Some recruitment information was unavailable. For example, of 6 staff files reviewed, 3 clinical staff did not have recorded employment references. We checked 6 staff files. Two contained DBS certificates dated 2015 and 2020. The remaining four staff files did not contain DBS certificates but only a record that a basic DBS check was carried out,

Systems to oversee staff training were not effective. Although training software was in place, managers had not established effective systems to monitor staff completion of mandatory training. Of 6 staff files reviewed, the training records of two clinical staff and one non-clinical staff member were incomplete. Safeguarding training was not fully compliant with intercollegiate guidance, and there was no record of completed fire safety training for 2 members of staff.

Records of staff vaccinations were incomplete and not maintained in line with Green Book guidance. Hepatitis B immunisation history had not been collected for three staff at risk of blood exposure. There was also insufficient recording of which staff were up to date with their routine immunisations, for example, tetanus, diphtheria, polio and MMR. Where staff declined immunisation, risk assessments had not been completed.

Leaders had not consistently prioritised staff development and appraisal. Six staff had not received an annual appraisal, and this had not been clearly identified by managers. The provider stated they would review appraisal processes following the inspection. Monthly protected learning time supported professional development.

Clinical supervision arrangements were effective. Staff received regular supervision, including daily GP debriefs. Audits of GP and nurse consultations demonstrated appropriate oversight. Leaders told us staff always worked within their job descriptions and competencies. We saw the PCN GP assistants who worked at the practice had suitable job descriptions and evidence of completed training.

There was insufficient evidence that staff had received training to support people with autism or learning disabilities. Three of five staff files reviewed did not include records of this training.

The facilities and premises were clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building. The provider assessed and managed infection risks. The practice had carried out an Infection Prevention and Control (IPC) audit in March 2026. At the time of our inspection, the GP Partner was acting as the IPC lead but explained that the role would shortly be taken over by the PCN senior nurse as the service had no permanent practice nurse. When we checked staff files, we found some staff had not completed mandatory IPC training relevant to their roles.

Staff told us regular checks of cleaning were conducted to maintain standards. However, staff could not show us a cleaning schedule and there was no system of checking which cleaning tasks had been completed by the cleaning contractor and that they had been done at the recommended frequency. The provider had a purpose-built storage space so cleaning equipment could be stored safely and in line with best practice. Clinical waste, sharps, and clinical specimens were managed appropriately to keep everyone safe. However, managers could not show us evidence of a waste consignment agreement. There was no Control of Substances Hazardous to Health (COSHH) risk assessment available. Staff could not show us any data sheets for substances stored on the practice premises. Staff we spoke with were not aware they had to have a COSHH risk assessment.

The practice had an infection control policy, last reviewed March 2026 which included reference to vaccination/immunity to hepatitis B for all staff who might come into contact with body fluids, clinical waste and sharps in the course of their duties. However, staff vaccinations were not always kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. Evidence of staff immunisation history was not available on the day of the site visit. There was a policy for reporting infection concerns to the relevant agencies, such as for notifiable diseases.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were completed with the consent of the provider, and to review if the practice was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance.

We reviewed clinical records for patients who had been prescribed medicines which required monitoring. Our review showed that regular medicines reviews were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs.

People taking medicines with specific risks that required monitoring, were not always appropriately monitored before their medicines were prescribed. Our clinical searches identified a small number of patients who had not always had appropriate monitoring;

For example,

Patients prescribed a disease-modifying antirheumatic drug (DMARDS) had not always received appropriate monitoring. A clinical search identified 20 patients taking the high-risk medicine methotrexate (a medicine used to suppress the immune system). We reviewed 3 patients prescribed methotrexate and found all 3 patients had not had required monitoring in the last 6 months. The practice escalation protocol to follow up non-responders was ineffective. All 3 did not have up to date blood tests in the record. One of the patients was under secondary care for monitoring. It was unclear as to whether alternative methods of communication were tried, and medication quantities adjusted to prevent potential harm.

There were 71 patients taking ACE inhibitors (a medicine used to treat high blood pressure) identified by a clinical search who had not had required monitoring (nearly 10%). We looked at 5 patients and found although monitoring was up to date, 3 out of 5 patients had not been responding to requests to come in for monitoring tests. The practice escalation protocol had not ensured that non-responding patients were followed up. There was no note recording what the next steps were for patients who were not compliant.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. The practice had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. However, when we checked, we found one emergency medicine was out of date which had not been picked up by staff. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.