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Bethany Medical Centre Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 December 2019

We carried out an announced focused inspection at Bethany Medical Centre on 16 October 2019. We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Safe

  • Effective

  • Well Led

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 Requires Improvement overall and Requires Improvement for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • The system for ensuring that all the required documentation to demonstrate safe recruitment and on-going staff suitability was not comprehensive.

  • The systems for ensuring the premises and equipment were safe for use were not comprehensive.

We rated the practice as requires improvement for providing effective services because:

  • The system for ensuring staff training was not comprehensive.

This rating for providing effective services has resulted in the population groups for effective also being rated as requires improvement.

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

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.

  • Staff worked together and with other organisations to deliver effective care and treatment.

  • There was good communication between staff and staff told us they felt well supported.

  • The practice sought the views of patients and staff and acted on them.

  • There was a focus on continuous improvement.

The area where the provider must make improvements are:

  • Systems and processes must be in place to ensure specified information is available regarding each person employed.

  • Ensure all premises and equipment used by the service provider are fit for use.

  • Ensure all staff receive training to promote safe working practices and patient safety.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements:

  • Update the safeguarding policies and procedures to include the range of abuse that patients could potentially experience.

  • The practice should consider obtaining a paediatric pulse oximeter.

  • Review the system to monitor safety alerts.

  • Formalise the system for reviewing the practise of clinical staff to ensure consultations, referrals and prescribing are appropriate.

  • Provide formal training to non-clinical staff in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

  • Introduce a comprehensive programme of quality improvement to ensure a more planned approach driven by external influences and practice learning needs.

  • Make a record of practice meetings.

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


Requires improvement






Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement