Beechwood Medical Centre

We carried out an announced inspection of the Beechwood Medical Centre (the service) on 16 September 2021. The inspection focussed on issues we identified at our previous inspection on 13 February 2020. Overall, the service is now rated as Good.

The ratings for the key questions considered at this inspection are:

• Are services Safe - Good
• Are services Well-led – Good

The ratings carried forward from our previous inspection are: -

• Are services Effective? – Good
• Are services Caring? – Good
• Are services Responsive? – Good

The full report of our previous inspection in February 2020 can be found on our website at:

https://www.cqc.org.uk/location/1-7973557259/reports

Following that inspection, we served requirement notices under Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• We identified that the service did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Patients’ needs were not always fully assessed, and care and treatment were not always delivered in line with current evidence-based guidance.
• There was insufficient evidence that all staff had received up-to-date training appropriate to their roles and responsibilities.
• Published data on clinical performance was mixed in relation to People with long-term conditions.
• The arrangements for governance and performance management did not always operate effectively.

The provider told us immediate steps had been taken to address our concerns and subsequently sent us a plan of the actions taken.

In addition to the requirement notices, we highlighted some other aspects of the service where the provider should make improvements:

• Continue with efforts to improve outcomes for people with long-term conditions, the uptake of cervical screening tests and childhood immunisation rates.
• Introduce and maintain a record of staff members’ immunisation status, in accordance with PHE guidance and the practice’s infection prevention and control policy.
• Introduce a system to monitor prescription forms used in the service’s three printers, in accordance with national guidelines on prescription security.

Why we carried out this inspection

We carried out this focussed inspection on 16 September 2021, looking at the identified breaches set out in the requirement notices to review the action taken by the provider. We also looked at the other aspects of the service where the need for improvement had been identified at our previous inspection.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, we have taken account of the circumstances arising from 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:

• A remote review patients’ records undertaken by our GP specialist adviser, undertaken before our site visit.
• A video conference with the provider to discuss the remote records review;
• A site visit, involving an interview with the provider and practice manager to consider the actions taken by the provider since our last visit and to review patients’ records.

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 found that:

• The provider had reviewed the care of the patients being prescribed high-risk medicines and those whose care involved medications referred to in two drug safety alerts. The provider had taken action in relation to the patients’ care.
• Revised relevant policies, adopted by the local federation, had been fully implemented and reviewed since our last inspection.
• Staff training requirements were up to date and a record of staff members’ immunisation status was maintained.
• We found the practice had instigated actions which were sufficient to meet the requirements of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The areas where the provider should make improvements are:

• Continue to work with the PCN pharmacist in developing and undertaking medication reviews in accordance with clinical guidance.
• Continue with work to improve outcomes for patients with diabetes and efforts to improve the uptake of cervical screening tests and childhood immunisation rates.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care