We carried out an announced desk-top review of Balance Street Practice on 22 July 2021. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key question: safe. Due to assurances we received from our review of information, we carried forward the ratings for the following key questions: effective, caring, responsive and well-led from our last inspection in July 2019. Overall, the practice is rated as Good. It is rated as good in safe, effective, caring, responsive and well-led, as well as in all the population groups.
Following our previous inspection in February 2019, the practice was rated Good overall and for key questions effective, caring, responsive and well-led. It was rated requires improvement for key question safe. We also rated the population group families, children and young people as requires improvement.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Balance Street Practice on our website at www.cqc.org.uk
Why we carried out this review.
This review was a focused review of information without undertaking a site visit inspection to follow up on:
- The key question safe
- The breach of regulations identified in the previous inspection
- Ratings were carried forward from the previous inspection which included the effective, caring, responsive and well led domains.
How we carried out the review
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 reviews differently.
This review was carried out in a way which did not involve visiting the practice. This was with consent from the provider and in line with all data protection and information governance requirements.
- 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
We based our judgement of the quality of care at this service on a combination of:
- what we found when we carried out the desk-top review.
- information from our ongoing monitoring of data about services and
- information from the provider and other organisations.
We have rated this practice as Good overall and good for all population groups.
We found that:
- The practice had actioned and put measures in place to comply with the Regulatory breach.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Systems had been put in place to ensure the proper and safe management of medicines.
- The practice had updated their records of skills, qualifications and training for all staff.
- Safeguarding policies had been updated and included all categories of abuse.
- A system had been developed to follow up children's non-attendance at secondary care appointments.
Whilst we found no breaches of regulations, the provider should:
- Continue to review their searches and protocols for high risk medicines.
- Further refine their safety alert process.
- Review significant event process to ensure the root cause identified.
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