A GP practice based in Burnham on Sea has been rated inadequate by the Care Quality Commission (CQC) and placed in special measures, following an inspection in July and August.
Burnham & Berrow Medical Centre, Burnham on Sea was inspected to follow up on breaches of regulation found at a previous inspection in August 2021.
Following the inspection, CQC imposed urgent conditions on the practice. The conditions focused on reviewing patients’ care and treatment; clearing the backlog of unactioned tasks and correspondence; ensuring all significant events raised in the practice were reviewed, necessary action taken and learning shared with practice staff. This was in relation to the significant concerns identified relating to patient safety and leadership and governance.
As well as being rated inadequate overall following the inspection, the practice was rated inadequate for being safe, effective, responsive to people’s needs and well-led. It was rated requires improvement for being caring.
As it is now in special measures, the service will be kept under close review by CQC. It will be inspected again to assess whether improvements have been made.
If insufficient improvement is made, CQC will take further enforcement action to ensure patients are not exposed to avoidable risk of harm. In the most serious of circumstances, this could include preventing the practice from providing care and treatment to people.
Neil Cox, CQC head of inspection said:
“Our inspection found standards of care at Burnham & Berrow Medical Centre, were well below those people have a right to expect due to a lack of effective leadership.
“The systems in place at the practice were not embedded enough to make sure people were safe and safeguarded from abuse. Neither could the practice leadership team demonstrate that they had the capacity and skills to deliver high quality sustainable care.
“It was difficult for people to access appointments and treatment, and there were delays in receiving their test results.
“Our priority is to keep people safe, and the practice knows what it must do to improve. To help them with this, local stakeholders such as Somerset Integrated Care Board are currently in the practice providing support and leadership.
“We will closely monitor the practice and reinspect them again in the coming months to assess whether the practice is compliant with its legal obligations, and to ensure a safe and high-quality service is being provided to all patients.”
Findings at the inspection included:
- Systems and processes to keep people safe were not effective
- Patient treatment was not always regularly reviewed and updated
- Patients with long-term conditions had not been proactively monitored throughout the pandemic. Due to a large backlog of correspondence there were delays in patients test results being reviewed
- Staff did not always treat patients with kindness, respect and compassion
- Services did not always meet patients’ needs
- Vulnerable patients could not be easily identified
- The practice did not have a system to learn and make improvements when things went wrong. Complaints were not managed effectively and learning from incidents was not routinely shared with all staff
- There was poor leadership and clinical oversight at the service
- Appropriate recruitment checks hadn’t always been carried out to ensure staff were suitable for their roles.