You are here

Berrymead Medical Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 22 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Berrymead Medical Centre on 13 September 2016. The overall rating for the practice was ‘requires improvement’. This was because we judged the practice as ‘requires improvement’ for being safe and for being well-led. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Berrymead Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 20 February 2017. The inspection was carried out to check that the provider had met the legal requirements we set out following the September 2016 visit. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Our key findings were as follows:

  • Improvements had been made to the governance systems to ensure that the quality of services was assessed, monitored and improved. These included; carrying out a health and safety related risk assessment that included control measures, reviewing the arrangements for clinical audit, the creation of a business continuity plan (emergency contingency plan) to manage unforeseen events or major incidents, improved structure and recording of practice meetings to promote good governance and the dissemination of information.

  • The provider had reviewed health and safety related policies and procedures.

  • An electrical installation safety test had been carried out.

  • A fire safety risk assessment had been carried out and new fire safety checks had been introduced.

  • A Legionella risk assessment had been undertaken and control measures were in place to prevent Legionella.

  • A practice specific infection control policy and procedure had been implemented.

  • The provider had introduced a system to ensure that all prescription pads were stored securely and accounted for.

As a result of the actions taken the practice is now rated as ‘good’ for providing a safe service and a well-led service. Overall the practice is therefore now rated as good.

We also found that the provider had made a number of improvements to the service in response to recommendations we made at our last inspection. These included;

  • Improvements in patient access to appointments and the telephone system.

  • Staff recruitment records had been improved to include documenting staff interviews and staff induction.

  • A documented schedule had been introduced for the cleaning and disinfection of medical equipment and clinical rooms.

  • A periodic review of complaints and significant events had been introduced in order to identify themes and trends.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 22 March 2017

The practice is rated as good for providing safe services.

  • The practice had systems, processes and practices in place to keep people safe.

  • Systems were in place for identifying risks and planning to mitigate these.

  • A system was in place to periodically review significant events.

  • Staff recruitment procedures included documenting the process for the selection and induction of new staff.

  • Systems for storing and accounting for prescriptions were in place.

Effective

Good

Updated 22 March 2017

Caring

Good

Updated 22 March 2017

Responsive

Good

Updated 22 March 2017

Well-led

Good

Updated 22 March 2017

The practice is rated as good for providing well-led services.

  • There were systems in place to govern the practice and support the provision of good quality care.

  • Arrangements were in place to identify risks and to monitor and improve quality.

  • The practice had a number of policies and procedures to govern activity and regular governance meetings were held.

Checks on specific services

People with long term conditions

Good

Updated 22 March 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 13 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 22 March 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 13 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 22 March 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 13 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 22 March 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 13 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 22 March 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 13 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 22 March 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 13 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.