20 April 2018
During a routine inspection
This practice is rated as Good overall.
(The Beeches Medical Centre is a new registered practice and this is the first inspection of the service under this provider.)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at The Beeches Medical Centre on 20 April 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.
At this inspection we found:
- The practice generally had clear systems to manage risk so safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. We saw there was a lack of risk management in some areas of fire safety and the storage of substances that were potentially hazardous to health; however, this was addressed immediately by the practice following our inspection.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines. There was a comprehensive programme of audit in place.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported they were able to access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw two areas of outstanding practice:
- The practice nurse had implemented a review of all patients over 75 years of age with no long-term health conditions. We saw evidence a total of 315 reviews had been carried out in the two years to April 2018, 154 of them in the first year. Of these 154 reviews, 94 had resulted in further referral for unmet needs. As a result of this work, the nurse had been invited to and attended a garden party at Buckingham Palace on 16 May 2017.
- The practice had purchased a computer software system that allowed for all aspects of practice governance to be managed safely and effectively. Managers had worked during the past year to populate this system to give full and comprehensive access to all staff in the practice as appropriate. This included for example, staff training records, recruitment records, meeting minutes, significant event records, patient safety alerts, practice policies and procedures and timely reminders for the governance of these documents.
The areas where the provider should make improvements are:
- Continue to implement and review the areas of safety risk assessment associated with the practice new fire policy and procedure and COSHH (control of substances hazardous to health) policy.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice