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Bethany Medical Centre Requires improvement


Inspection carried out on 16/10/2019

During an inspection looking at part of the service

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 carried out on 18 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bethany Medical Centre on 18 March 2015. Overall the practice is rated as good.

Bethany Medical Centre provided safe, effective, responsive care that was well led. The service was caring and compassionate and met the needs of the population it served.

Our key findings across all the areas we inspected were as follows:

  • Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons learnt from the investigation of safety incidents were disseminated to staff. Infection risks and medicines were managed safely.

  • People’s needs were assessed and care was planned and delivered in line with current legislation and guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned. Patients experienced clinical outcomes that were in line with or above the national average.

  • Patients spoke highly of the practice. They said they were treated with care, compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

  • The practice provided good care to its population that was responsive to their health needs. Patients were listened to and feedback was acted upon. Complaints were managed appropriately. Patients said they found it easy to make an appointment with a named GP and that there was good continuity of care, with urgent appointments available the same day.

  • There was a clear leadership structure, staff enjoyed working for the practice and felt well supported and valued. The practice monitored, evaluated and improved services. The practice proactively sought feedback from staff and patients, which it acted on.

There were areas of practice where the provider needs to make improvements.

The provider should:

  • Implement a system for identifying and managing local risks associated with the practice. For example general environmental and health and safety risk assessments including the risks presented by legionella. (A bacterium found in the environment which can contaminate water systems in buildings).
  • Ensure its recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held.
  • Ensure that all staff are suitably trained and updated in emergency procedures such as basic life support and fire drill training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice