You are here

Drs Green, Broadbelt and Majeed Good

Inspection Summary

Overall summary & rating


Updated 15 October 2019

We carried out an announced comprehensive inspection at Drs Green, Broadbelt and Majeed (Also known as Vittoria Medical Centre) on 12 September 2019.

This inspection was to follow-up on breaches found at the previous inspection in March 2019 at which we found breaches in Regulation 12, Safe care and treatment because high risk medicines were not managed safely and Regulation 16 because complaints were not dealt with in keeping with the regulations. At this follow up inspection we found action had been taken to ensure high risk medicines were managed safely and processes had been put in place to ensure complaints were dealt with correctly.

We found however, that systems and processes in place to support effective and sustained improvements needed strengthening.

We looked at all five key questions.

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 good overall and good for all population groups.

We rated the practice as good for providing safe, effective, responsive and caring services.

We have rated this practice as requires improvement in well-led.

We found:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. At the previous inspection systems were not in place to ensure patients on high risk medicines had the required health checks to keep them safe and medicine safety alerts had not been responded to as required. At this follow-up inspection systems had been put in place to promote patient safety. The systems included identifying and keeping in touch, appropriately, with all relevant patients.
  • Patients generally received effective care and treatment that met their needs. We saw that clinicians treated and cared for patients in line with current best practice guidelines.
  • The practice delivered care and treatment tailored to the individual’s needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way. At the previous inspection the practice did not deal with complaints and comments openly or provide enough information about how to complain. At this inspection the practice had made improvements and could show they had listened to the complainant and addressed complaints correctly. Patients were provided with the information and support needed to raise concerns and information about how to contact the Parliamentary and Health Services Ombudsman was provided.

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

  • The leadership style and ethos promoted the delivery of high-quality, person-centre care however, the managerial systems did not fully support the delivery of safe and effective services.
  • Recent procedural changes had been implemented or were planned, for example: the contents of GP bags were now regularly checked; a new policy to manage prescriptions was in place; plans to scrutinise antibiotic prescribing had been discussed and the development of the clinical audit plan. However, processes needed to support on-going changes were not embedded.
  • Analysis of information gathered by the provider lacked detail and did not identify possible areas for improvements. For example, from patient surveys; fire drills or training and recruitment records.
  • A clinical audit program had been recently developed however, an operational audit program had not been developed.
  • Key roles had not been allocated for example an infection prevention and control lead had not been identified.

The area where the provider must make improvements is:

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

The area where the provider should make improvement is:

  • Consider providing a data logger for both vaccine fridges.

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

Inspection areas


Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable