Billet Lane Medical Practice

Updated 22 August 2023

Billet Lane Medical Practice is located in Hornchurch at:

58b

Billet Lane

Hornchurch

RM11 1XA

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. These are delivered on site.

The practice is situated within the NHS North East London and delivers (Personal Medical Services (PMS) to a patient population of about 3600. This is part of a contract held with NHS England. Billet Lane Medical Practice is located in a purpose built 1970s building, which has been extended to provide additional consultation rooms. Billet Lane Medical Practice is co-located with another GP Practice. The practice is accessible with ramp access, disabled toilets and access to consultation rooms at ground floor level.

The practice is part of the NHS North East Integrated Care System in the London borough of Havering. Billet Lane is also part of the Havering Crest Primary Care Network (PCN) and works with other local practices to improve the quality of healthcare for the local populations.

There are 3600 patients registered at the practice with a mixed demographic of working age families and older adults.

Information published by the Public Health England rates the level of deprivation within the practice population group as ninth on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

The clinical staff includes 1 full-time partner GP who is also the provider (a female) working 8 sessions each per week supported by 2 long-term locum doctors (1 male, 1 female), each working 2 sessions per week. The practice clinical team also includes 1 part time female practice nurse who works 4 sessions per week and an advanced nurse practitioner who also works 4 sessions per week. The practice has 10 staff in its administrative team including a practice manager.

The practice's opening hours are Tuesday, Wednesday, Thursday, Friday 8.00am to 6.30pm and Monday 8am to 7.30pm. The practice is closed on Saturday and Sunday. The practice's appointments are available from: mornings 8am to 12pm and afternoons 3pm to 5.30pm. With the exception of Monday when appointments are available from 9am to 12 pm and 4pm to 7.20pm.

Patients can book appointments in person, on-line or by telephone. Patients can access a range of appointments with the GPs and nurses. Face to face and telephone appointments are available on the day, and are also bookable up to two weeks in advance.

Updated 22 August 2023

We carried out an announced comprehensive inspection) at Billet Lane Medical Practice on 5, 12 and 20 July 2023. Overall, the practice is rated as requires improvement.

Safe - Requires Improvement.

Effective - requires improvement.

Caring - good.

Responsive - requires improvement.

Well-led - requires improvement.

Following our previous inspection on 27 July 2022, the practice was rated requires improvement overall and for the key questions safe, effective, responsive, and well-led.

The full reports for previous inspections can be found by selecting the 'all reports' link for Billet Lane Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up breaches of regulations 12,17 and 18 of the Health and Social Care Act 2008 from a previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice's patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from 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 found that:

• The practice had a list of approximately 3,500 patients, the premises were limited and there was a small staff team, which had meant that informal systems had developed. Therefore, the governance systems in place for recruitment, patient referrals, and the safe monitoring of medicines, were not always robust and effective.
• The practice did not always have effective arrangements in place for managing risk regarding emergency medicines, and safety alerts.
• The practice had made some improvements following the previous inspection in July 2022 in staff training and the introduction of policies and procedures. However, further work was required to ensure all policies reflected staff practices.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The GP Patient survey results for the patient's access to the service were below national average.
• Clinical searches found patients receiving high-risk medicines, such as methotrexate, leflunomide and azathioprine potassium-sparing diuretic received appropriate monitoring.
• Staff were positive about the working at the service.
• The overall management of training had improved.
• The practice had made improvements to some of the policies and procedures.
• The system for the management of infection management and control was effective.
• The systems for the management of risk in the premises was effective.

We found two breaches of regulations. The provider must:

• 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.

The provider should:

• Improve and formalise the monitoring of the children's safeguarding register.
• Take action to record the reviews of significant events at clinical meetings and complete a significant event log.
• Continue to improve staff uptake of training and the practices assurance of staff competencies for their roles.
• Improve schedule of clinical audits to monitor and improve patient's clinical care. demonstrate a quality service.

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

Dr Sean O'Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care