The Belgrave Medical Centre

We carried out an announced comprehensive inspection at The Belgrave Medical Centre on 6 July 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - inadequate

During the inspection process, the practice highlighted efforts they are making to improve outcomes and treatment for their population. These had only recently been implemented so we were unable to assess the impact of these improvements. As such, the ratings for this inspection have not been impacted. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.

Why we carried out this inspection

We carried out this inspection in response to concerns reported to us and because the new provider had yet to be rated since registration in November 2021. We reviewed all key questions as part of this 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 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 did not always provide care in a way that kept patients safe and protected them from avoidable harm as the practice did not have effective systems for the appropriate and safe use of medicines.
• People with some long-term conditions did not receive effective care and treatment that met their needs.
• Patients rated the practice in line with local and national averages for questions relating to the care they received.
• Patients could access care and treatment in a timely way.
• The overall governance arrangements were inadequate as we identified concerns which did not promote the delivery of high-quality, person-centred care.

We found a breach of regulations. The provider must:

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

The areas where the provider should make improvements are:

• Take action to ensure the process of monitoring blank prescriptions is sustained.
• Improve the risk assessment process to determine if staff are required to undertake a DBS check.
• Improve managerial oversight of staff mandatory training.
• Improve uptake of cervical screening for the benefit of eligible patients.
• Take action to improve communication between senior leaders.
• Continue to establish an active Patient Participation Group (PPG).

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