- GP practice
Archived: Beechwood Group Practice
Important:
The provider of this service changed. See new profile
All Inspections
19 January 2018
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 Beechwood Group Practice on 14 April 2016. The overall rating for the practice was requires improvement. After the comprehensive inspection the practice wrote to us to say what they would do to address the areas which required improvement. We undertook an announced focused inspection on 15 December 2016 to check that the practice had followed their plan and to confirm that they now met legal requirements The overall rating of the practice was changed to good, but remained rated as requiring improvement for leadership. The full comprehensive report on the April 2016 inspection and the report for focused inspection in December 2016 can be found by selecting the ‘all reports’ link for Beechwood Group Practice on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 19 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 December 2016. This report covers our findings in relation to those requirements.
The practice is rated as good overall including for providing safe services.
Our key findings were as follows:
-
The practice had addressed the governance arrangements to ensure that the programme of clinical audit at the practice was effective, and that significant events were suitably analysed and actioned, and that learning from them was shared.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
15 December 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We previously carried out an announced comprehensive inspection of this practice on 14 April 2016. Breaches of legal requirements were found. Overall, we rated the practice as requires improvement.
After the comprehensive inspection the practice wrote to us to say what they would do to address four identified breaches of regulation. We undertook this focused inspection on 15 December 2016 to check that the practice had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection and our focused inspection by selecting the ‘all reports’ link for Beechwood Group Practice on our website at www.cqc.org.uk.
Overall the practice is now rated as good.
Our key findings across all the areas we inspected were as follows:
- The practice had taken action to address most of the concerns raised at the CQC inspection in April 2016. They had put measures in place to ensure they were compliant with two of the three requirement notices we served following the initial inspection.
- There was an improved approach to recording and responding to significant events, however, there were still some improvements required to make this effective.
- Appropriate checks were carried out on new staff employed by the practice.
- An effective system for recording and monitoring staff training had been implemented and all mandatory staff training had been completed.
- The arrangements for the management of health and safety at the practice had been reviewed. This was a recommendation made to the practice following the last inspecton.
- A handwashing audit had been performed, however, there had been no infection control audit completed for the practice premises at the time of inspection. The latter was a recommendation made to the practice following the inspection in April 2016.
- The practice had not yet reviewed the arrangements for the management of complaints, as recommended at the inspection in April 2016.
- The practice had undertaken a range of clinical audits since the last inspection, however these were not of a sufficient standard to demonstrate quality improvement.
There were areas of practice where the provider must make improvements:
- Address the governance arrangements to ensure that the programme of clinical audit at the practice is effective, and that significant events are suitably analysed and actioned, and that learning from them is shared.
There were areas of practice where the provider should make improvements:
- Complete an infection control audit for the practice premises.
- Follow national guidance concerning the recording of complaints, and how these are reviewed and responded to.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
14 April 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Beechwood Group Practice on 14 April 2016. Overall, the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responses to raise concerns and to report incidents and near misses. However, the systems in place at the practice were not effective and this resulted in incidents and near misses not always been effectively managed or recorded.
- Some risks to patients were assessed and well managed, with the exception of those related to recruitment, some areas of health and safety.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
- Not all staff had the skills, knowledge and experience to deliver effective care and treatment. For example, we identified that not all staff had competed safeguarding, infection control or information governance training.
- 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. However, the practice did not manage complaints in line with their agreed policy.
- Extended hours appointments were available each Saturday morning from 9am to 12:30pm.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- There was a clear leadership structure and most staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
- The practices ethos complied with the requirements of the duty of candour. However, the practices’ record keeping process for complaints and significant events did not support the requirements of duty of candour.
There were areas of practice where the provider must make improvements:
- Introduce effective procedures for reporting, recording, acting on significant events, incidents and near misses and ensure that learning is shared with all relevant staff.
- Ensure staff receive appropriate staff training for their role, for example safeguarding and infection control and carry out annual staff appraisals.
- Ensure the recruitment of all staff includes all the necessary employment checks and records are kept of these.
- Review the governance arrangements at the practice. Ensure that appropriate records are maintained in relation to the governance of the practice, specifically in relation to records of meetings. Review the arrangements for clinical audit to ensure standards are clearly defined, and there is a clear link between audits and improvement in the quality improvement.
There were areas of practice where the provider should make improvements:
- Review the arrangements for the management of health and safety at the practice
- Complete an infection control audit for the practice.
- Review the arrangements for the management of complaints including ensuring all complaints are recorded, reviewed and responded to in line with national guidance.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
27 January 2014
During an inspection looking at part of the service
We found that all staff had completed safeguarding training at level 1, and some staff were to attend level 2 training in May 2014. The new practice manager was aware that the recruitment process was unsafe but since their appointment they had introduced a robust recruitment process. This ensured that staff employed were suitable for the role they were to undertake.
We saw that cleanliness was now of a good standard. A deep clean had been undertaken by a cleaning company and a contract had been entered into with this company for the ongoing cleaning of all areas of the practice. However security arrangements remained a concern as it was possible for people to enter the rear of the premises, via the disabled access, and walk through the premises to the reception area unobserved. We reinforced this with the provider that it was urgent that this work be carried out given the risk.
During this inspection we saw evidence that staff training had been improved. One member of staff stated that since the last inspection there had been, 'Massive changes 'with cleaning, staff training, and in a number of areas'. Another member of staff commented that they were working through the on line training and found this, 'Helpful'.quite good'.
Although the practice manager had not been able to develop an effective system to regularly assess and monitor the quality of service that people received since she had been employed, she could confirm, and we saw, that she had an action plan in place to take this forward. This would ensure that the premises and service provision was monitored to ensure quality and safety.
7 August 2013
During a routine inspection
We did find that the doors to all surgeries were not locked when not in use. All rooms were not situated in the sight line of the receptionists. D'cor throughout the building was generally dated, apart from the treatment rooms which had been refurbished a few years ago. The general standard of cleanliness throughout the premises was poor. Evidence was not available to support that staff had undertaken mandatory and or workplace appropriate training. There was no apparent system in place for the recording, monitoring and maintaining of staff training records. We asked about audit activity undertaken by the practice. However, there was no programme of systematic audits undertaken other than the QOF requirements so the provider could not demonstrate to us how they assessed and monitored the quality of the service provided.