Beeston Village Surgery

We carried out an announced comprehensive inspection at Beeston Village Surgery on 12 and 14 July 2022.

Following this inspection, we rated the location as good overall and the following for each key question:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Why we carried out this inspection

This announced comprehensive inspection was carried out following changes to the provider registration and legal entity of the practice. This was the first inspection since this change.

Under their previous registration, the practice was inspected on 17 April 2018. At that inspection, the practice was rated good overall and for all key questions of safe, effective, caring, responsive and well-led. The full report for that inspection can be found by selecting the ‘all reports’ link for Beeston Village Surgery on our website at www.cqc.org.uk

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:

• Requesting evidence from the provider.
• Conducting some staff interviews via telephone.
• Practice staff completing questionnaires.
• 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
• A short site visit

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.

We found that:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns.
• Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Staff had the skills, knowledge and experience to deliver effective care.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.

Whilst we found no breaches of regulations, the provider should:

• Embed and monitor the revised process for the management of patient safety alerts.
• Improve the recall and follow-up processes for the monitoring of patients who are prescribed high-risk medicines.
• Improve the recall and follow-up processes for the monitoring and coding of patients who may be identified as pre-diabetic.

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