Background to this inspection
Updated
24 September 2021
Bethany Medical Centre is located in St Helens, Merseyside at:
151 Grafton Street
St Helens
Merseyside
WA10 4GW
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the St Helens Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of 4,185. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices (St Helens North Primary Care Network).
Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 98.3% White and 0.8% Asian.
The practice currently has two GP partners. There is also an advanced nurse practitioner and a health care assistant who is training to be a GP assistant. One of the GP partners is leaving the practice and is being replaced as a partner by the advanced nurse practitioner. A plan is in place to ensure sufficient GPs are available in the interim. There is currently a vacancy for a practice nurse and locum nurses are currently being used. The clinicians are supported at the practice by a practice manager and reception and administration staff. The practice hosts medical students from the University of Liverpool.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then this is offered.
Extended access and out of hours services are organised locally by St Helens CCG.
Updated
24 September 2021
We carried out an announced inspection at Bethany Medical Centre on 26 August 2021. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Well-led - Good
Following our previous inspection on 16 October 2019, the practice was rated Requires Improvement overall. It was rated Requires Improvement for providing Safe and Effective services and Good for providing Caring, Responsive and Well-led services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bethany Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up review of information which included a site visit to follow up on:
- Breaches of regulations and ‘shoulds’ identified in the previous inspection.
- Ratings for Responsive and Caring were carried forward from the previous inspection.
How we carried out the inspection
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 inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Staff questionnaires
- Requesting evidence from the provider
- A site visit
- 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
Our findings
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 found that:
- The provider had taken action to improve the service provided following the last inspection.
- Improvements had been made to ensure staff had the training they needed for their roles.
- The required recruitment and on-going checks to ensure staff suitability for employment were being undertaken.
- The system to ensure the premises and equipment were safe had improved.
- Policies and procedures had been reviewed, including the safeguarding procedures. The system to monitor safety alerts had been reviewed. A paediatric pulse oximeter had been obtained, the system to monitor the competence of non-medical prescribers had improved. A programme of quality improvement had been introduced.
- 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.
Whilst we found no breaches of regulations, the provider should:
- Record the measures in place to promote the security of the building, equipment and information.
- Review the system to manage prescriptions so that it is clear which clinician each prescription has been allocated to.
- Review the monitoring frequency of patients prescribed Spironolactone.
- Hold information relating to complaints in one record so that this can be easily accessed and reviewed.
- Introduce a system to carry out a review of Do Not Attempt Cardiopulmonary Resuscitation Orders (DNACPR) that are initiated at hospital and a system to ensure that mental capacity assessments are consistently recorded.
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