The Care Quality Commission
  • Doctor
  • GP practice

Bedford Hill Family Practice

Overall: Good read more about inspection ratings

120 Bedford Hill, Balham, London, SW12 9HS (020) 8673 1720

Provided and run by:
Bedford Hill Family Practice

All Inspections

11 May 2022

During an inspection looking at part of the service

We carried out an announced inspection at Bedford Hill Family Practice on 11 May 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Requires Improvement

Well-led - Good

Following our previous inspection on 6 October 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bedford Hill Family Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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 requires improvement overall

We found that:

  • The practice was equipped to respond to medical emergencies and staff were suitably trained in emergency procedures.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health.
  • 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.

We found one breach of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way for patients.

(Please see the specific details on action required at the end of this report).

We also found that the provider should:

  • Consider ways to log significant events and complaints to allow for themes to be identified and learning to be shared effectively.
  • Continue to take action to improve uptake of childhood immunisations and cervical screening.

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

6 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bedford Hill Family Practice on 6 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed. However, the temperature gauge on one of the refrigerators was not reading correctly.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Consider recalibrating temperature gauges or replacing vaccine refrigerators, although interior temperature gauges were showing correct temperatures, on one of the refrigerators the gauge on the refrigerator was showing temperatures outside of the safe range.

  • Consider responding to complaints in the same means that the complaint was made, and including Ombudsman details in written responses.

  • Consider which meetings should be minuted.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice