The Care Quality Commission
  • Doctor
  • GP practice

Beccles Medical Centre

Overall: Good read more about inspection ratings

St Mary's Road, Beccles, Suffolk, NR34 9NX (01502) 712662

Provided and run by:
Beccles Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Beccles Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Beccles Medical Centre, you can give feedback on this service.

01 March 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Beccles Medical Centre on 1 March 2022.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. 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.

During this inspection we also considered the management of access to appointments.

The practice was previously inspected in January 2019 when it was rated Good overall and Requires Improvement for providing Safe services. This inspection was followed up in December 2019, when we inspected only the key question Safe and, on this occasion, we rated it as Good.

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

We have rated this practice Good overall

Safe - Good

Effective - Good

Well-led - Good

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account 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

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 Good overall

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Safeguarding was a standard item on the agenda of the monthly clinical meeting.
  • The practice had developed a process on their computer system where staff were able to raise any concerns. This was monitored by the safeguarding deputy lead.
  • We saw evidence of a number of safeguarding courses delivered to staff by the safeguarding lead.
  • The infection prevention control (IPC) lead had remained updated with the Covid-19 guidance from NHS England infection throughout the pandemic.
  • Emergency, and anaphylactic shock medicine was stored securely, and the expiry dates and stock levels were documented monthly along with the oxygen, and defibrillator. There was appropriate signage for this equipment.
  • All significant events were discussed at clinical meetings and the learning shared via smaller team meetings.
  • Although the practice did have a system in place to record and act on safety alerts, we identified one alert which had been issued in the past which had not been acted on.
  • Whilst overall, we found that medicine reviews were being carried out adequately, we found that there were some concerns.
  • Patients received effective care and treatment that met their needs.
  • The practice used standard software templates to ensure patient care and treatment was coded to provide consistent standards of care.
  • The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements.
  • We saw evidence that clinicians took part in multi-disciplinary team, (MDT) meetings to discuss patient care.
  • The practice used their website and social media accounts to provide information to patients about various health initiatives.
  • The practice used the Daffodil Standards for General Practice which is an evidence-based framework to help staff self-assess and offer the best end of life and bereavement care for patients
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had introduced assistive technology to support those patients attending the practice who had a hearing or sight impairment.
  • 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.
  • During the COVID-19 pandemic, face to face appointments continued to be offered following triage by a clinician.
  • At the time of inspection, the practice was fully open and offered a range of appointment types to patients.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice had put in place daily duty operational managers and duty clinicians who were able to respond to any concerns identified by staff or patients.
  • Leaders actively promoted the well-being of staff
  • There had been a re-structure of roles and responsibilities at the practice just before the start of the COVID 19 pandemic. Staff were clear what was expected of them in their new roles.
  • There was a strong focus on learning and development, with the practice having its own training facility.

At the previous inspection in December 2019, we identified that the practice should continue to monitor and improve patient satisfaction with accessing the practice via the telephone.

At this inspection, we found that this concern had been addressed with the installation of a new telephone system and additional staff.

Whilst we found no breaches of regulations during this inspection, the provider should:

  • Review and monitor the process for acting on safety alerts, to minimise the risk of any patients missing a medicines review.
  • Review and monitor the procedures for medicines management, to minimise the risk of any patients not receiving the required monitoring required for the medicines they are prescribed.
  • Continue to improve patient satisfaction in relation to the ease in which patients are able to contact the practice by phone.

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

19 Dec to 19 Dec 2019

During an inspection looking at part of the service

We undertook an inspection of this service on 19 December 2019 following our annual review of the information available to us. This inspection was to follow up on the breach of regulation identified at our previous inspection in January 2019 and we looked at the safe key question only.

Our judgement of the quality of care at this service is based 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 good overall.

At this inspection we found that the provider was proving safe services because:

  • The service had completed a health and safety risk assessment and identified actions had been completed. The service had appointed a site facilities officer who continually reviewed risk within the practice and three members of staff had completed enhanced health and safety training.
  • The service had appointed an education and training officer who monitored compliance with training and set protected time for staff to complete training. Protected time was given at induction to complete training. We saw that all staff were up-to-date with training the practice deemed mandatory.
  • The service had appropriate oversight of staff immunisation records.
  • Significant events were a standard item agenda on all clinical and non-clinical staff meetings for effective sharing of learning.

In addition, we found that:

  • The practice had generally improved patient satisfaction with accessing the service. We saw one indicator was lower than average relating to patient satisfaction with getting through to the practice by telephone. The practice was aware of this and since the last inspection had introduced an online consulting tool that had addressed the concerns regarding telephone access and opening hours. This allowed patients to submit requests online which released more capacity on the telephone lines. Since the introduction of this system, the practice had noted a decline in patient complaints to the practice and of negative comments NHS Choices relating to accessing the service.

The area where the practice should make improvements:

  • Continue to monitor and improve patient satisfaction with accessing the practice via the telephone.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP
Chief Inspector of General Practice

09 Jan to 09 Jan

During a routine inspection

We carried out an announced comprehensive inspection at Beccles Medical Centre on 9 January 2019 as part of our inspection programme. The practice was previously inspected in March 2016 and rated as good overall and outstanding for providing well led services.

Our inspection team was led by a CQC inspector and included a GP specialist advisor and a practice manager specialist advisor.

Our judgement of the quality of care at this service is based 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 good overall.

This means that:

  • People were protected from avoidable harm and abuse and that legal requirements were met.
  • Patients had good outcomes because they received effective care and treatment that met their needs.
  • The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and drive care. For example, the practice regularly reviewed data from the Clinical Commissioning Group and used this to drive improvement within the practice.
  • Patients were supported, treated with dignity and respect and were involved as partners in their care.
  • People’s needs were met by the way in which services were organised and delivered. For example, the practice had engaged with the Social Prescribing and MIND charities to enable patients to be seen in a familiar environment.
  • The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
  • The practice encouraged continuous improvement and innovation. For example, the practice had a diverse skill mix within the practice and encouraged staff to undertake further education.
  • Staff reported they were happy to work in the practice and proud of the changes that had been made.

We saw an area of outstanding practice:

  • The practice had a Care Services Integration Project team (CSIP); the team saw patients who had been discharged from hospital, vulnerable patients and housebound patients. The team consisted of a community matron, respiratory nurse specialist, emergency care practitioner and a GP. If the team wished to discharge a patient, the GP would review and authorise where appropriate. The team managed patients with complex needs and reviewed all patients over 75 who had been admitted to hospital or had attended Accident and Emergency. The aim of the team was to reduce unplanned admissions to hospital. In the past 12 months, the team had prevented 256 GP home visits and 59 admissions to hospital.

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

  • Not all staff had received training in areas including safeguarding, infection prevention and control, fire safety and chaperoning. Although the practice reported the immunisation of staff was checked on employment, there was not documented evidence for all clinical staff. The health and safety risk assessments completed were not comprehensive and did not address all risks within the practice. The practice did not share the learning of all significant events.

We found the provider must:

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

We found the provider should:

  • Continue to review and improve outcomes relating to access in the GP Patient Survey.
  • Share the learning from all significant events to ensure staff are informed of changes.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

6 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beccles Medical Centre on 6 October 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring and responsive services. We found the practice was outstanding for providing well-led services. It was also good for providing services for older people, people with long-term conditions, families children and young people, working age people (including those recently retired) people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).

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 and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. There was a strong learning culture within the practice. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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 overall were happy with the appointment system because they were able to get telephone advice or be seen that day. However, some patients, particularly those of working age found the call back system was not always convenient for them to manage. The practice did offer flexibility to help meet patients' needs wherever possible for example, by arranging call backs at more convenient times with a named GP. Continuity of care was promoted by providing patients with urgent appointments that same day. This was usually with the GP who had dealt with the initial call.
  • 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 areas of outstanding practice including:

  • The practice had a clear vision that was shared and owned by staff. They followed structured policies and processes to deliver high standards of care. Performance and governance arrangements were proactively reviewed. Leadership responsibilities were appropriately delegated and staff were able to demonstrate this worked well in practice. The clinical team shared decision making (clinical and non-clinical) and worked effectively through clear communication and mutual support. There was a strong culture of shared learning and improvement to ensure that patients' needs were met.

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

Importantly the provider should

  • review the Chaperone policy with staff to ensure they all understand their role as a chaperone.
  • ensure that any recommendations made following the legionella management and risk assessment in January 2014, are actioned.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice