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Archived: BHSF Medical Practice Requires improvement

This service was previously registered at a different address - see old profile


Inspection carried out on 12 June 2019

During a routine inspection

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at BHSF Medical Practice as part of our inspection programme.

The service was previously inspected in June 2018 as Newhall Medical Practice - Newhall Street under the provider organisation,The Newhall Medical Practice Limited. We found the service was not providing safe and well led services and there were breaches in regulation 13 and 17 for which we issued requirement notices.

The service became part of the provider organisation, BHSF Medical Limited in 2015, and moved address in May 2018, to Cornerblock, 2 Cornwall Street, Birmingham B3 2DL, this had resulted in some changes to the senior management team as the service operated the BHSF corporate governance structure. At the time of our inspection in June 2018, these changes had not been reflected in the CQC registration. Following our inspection, the practice updated its registration. BHSF Medical Practice registered with CQC as a location for the provider BHSF Medical Practice Ltd in October 2018.

The Chief Medical Officer is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

As part of our inspection we also asked for CQC comment cards to be completed by patients prior to our inspection. We received 27 completed comment cards where people who used the service shared their views and experiences of the service. All comments received were positive about the service.

Our key findings were:

  • There were some systems and processes in place to keep people safe. However, these were not always identified, sufficiently well managed or embedded to ensure their effectiveness.
  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care, feedback we received from patients was positive.
  • The service took account of patient needs and preferences. Patients could access the service in a timely manner.
  • There was a lack of effective leadership oversight to ensure good governance. Systems and processes were not always embedded to ensure risks were identified and managed.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(You can see full details of the regulations not being met at the end of this report).

The areas where the provider should make improvements are:

  • Develop a systematic programme of ongoing quality monitoring and improvement activity.
  • Review the arrangements in place for supporting patients who may experience barriers to accessing the service, to ensure they can access and use services on an equal basis to others.
  • Consider ways to increase patient feedback to help improve the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care