The Care Quality Commission
  • Doctor
  • GP practice

The Bethesda Medical Centre

Overall: Requires improvement read more about inspection ratings

Palm Bay Avenue, Cliftonville, Margate, Kent, CT9 3NR (01843) 209300

Provided and run by:
The Bethesda Medical Centre

All Inspections

23 February 2022

During a routine inspection

We carried out an announced inspection at The Bethesda Medical Centre on 23 February 2022. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Good

Caring – Not inspected

Responsive – Inspected but not rated

Well-led - Requires Improvement

Following our previous inspection on 2 November 2015, the practice was rated Good overall and for all key questions except for Effective which was rated Outstanding.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Bethesda Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a focused comprehensive which focused on the Safe, Effective and Well-Led key questions. We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Kent and Medway. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of 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:

  • Conducting staff interviews using video conferencing .
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • A staff questionnaire.

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 have rated this practice as Requires Improvement overall

We found that:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • Patient views were acted on to improve services.
  • Staff felt supported by their managers and that their well-being was prioritised.
  • Staff had the training and skills required for their role.

We rated the practice as requires improvement for providing safe services because:

  • Audits of infection prevention and control were not sufficient.
  • Vaccines were not always appropriately stored and monitored in line with national guidance to ensure they remained safe and effective.
  • The practice did not have an effective system for monitoring significant events and ensuring that actions to improve safety had been implemented.
  • Blank prescriptions were not kept securely, and their use monitored in line with national guidance.

We rated the practice as requires improvement for providing well-led services because:

  • Leaders lacked oversight of some processes and therefore failed to identify risks when those processes did not operate as intended.

We found two breach of regulations. The provider must:

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

In addition, the provider should:

  • Maintain an up to date safeguarding register.
  • Ensure records are kept of monthly checks of emergency equipment.
  • Ensure patients with long term conditions receive up to date monitoring, in particular those with hypothyroidism and chronic kidney disease.
  • Improve childhood immunisation rates so that the minimum 90% target is met for all five indicators.
  • Improve cervical screening rates so that the Public Health England 80% coverage target is met.
  • Develop a formal programme of targeted audit and quality improvements.
  • Continue to review patient access and ease of getting through on the phone.
  • Consider holding practice meetings that include all staff.
  • Consider holding multi-professional meetings to aid communication and enable the sharing of good practice.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

2 November 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bethesda Medical Centre on the 17 February 2015. A breach of the legal requirements was found. Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breach.

We undertook this focused inspection on the 2 November 2015, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Bethesda Medical Centre on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bethesda Medical Centre on the 17 February 2015. Overall the practice is rated as good.

We found the practice to be outstanding for providing effective services and good for providing caring, responsive and well-led services. It was also good for providing services to older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students) and for people experiencing poor mental health (including people with dementia). It was rated outstanding for people whose circumstances may make them vulnerable. The practice required improvement for providing safe services and the concerns which led to this rating applied to all population groups.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles, with the exception of some areas of training that had not been updated or undertaken, although further training needs had been identified and training planned.
  • Recruitment procedures were not always used effectively when employing staff, as not all staff had undergone criminal records checks and the risks had not been assessed in relation to this.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they generally found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw some areas of outstanding practice:

  • The practice worked in partnership with two other local practices to initiate a pilot scheme to provide an ‘out of hours’ on-call service with a paramedic practitioner, to respond, visit and support care home residents, who became unwell. The scheme had been developed to avoid unnecessary visits to the local hospital accident and emergency department. The latest data indicated that over a twelve week period, of the residents seen by the paramedic, 95% had remained at home, rather than being transferred to hospital by ambulance.
  • The practice was located in an area of high deprivation and supported a range of patients with complex needs, including disadvantaged families who lived in vulnerable circumstances. A GP from the practice was involved in ‘street work’ activities with local support groups, including a ‘task force’ partnership. This involved approaching local families on a ‘one-to-one’ basis to promote health care services, many of whom had not registered with a GP. The group had received an ‘innovation collaboration award’ in recognition of their achievements in reaching out to vulnerable people in the local community, particularly those experiencing mental health problems.
  • The practice had arranged an ‘outreach day’ at a local hotel to offer support to people who found it difficult to access GP services, and were sign-posted to other agencies and services who could help support their needs. The practice had registered many patients at the event and there was a particular focus on children who lived in vulnerable circumstances, in promoting childhood immunisations, as well as family planning and follow-up health care provision at the practice.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider MUST:

  • Review the arrangements for DBS checks for administration staff who undertake chaperone duties.

Also, the provider SHOULD:

  • Review the staff training requirements in relation to chaperone duties, the Mental Capacity Act 2005 and infection control.
  • Review the processes for assessing the risks associated with legionella.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice