The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Beechdale Surgery

Overall: Requires improvement read more about inspection ratings

439 Beechdale Road, Nottingham, Nottinghamshire, NG8 3LF (0115) 929 0754

Provided and run by:
JRB Healthcare

Important: The provider of this service changed. See new profile

All Inspections

18 June 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at The Beechdale Surgery on 18 June 2019 in response to concerns that were found at another practice which was part of the Beechdale Medical Group.

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 and requires improvement for all population groups.

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

  • There were gaps in staff recruitment, immunisation and training records.

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

  • There was limited evidence of quality improvement.

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

  • The practice did not have a clear vision and set of values in place which staff were aware of.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider should make improvements are:

  • Encourage non-clinical staff to complete a level of safeguarding training in line with Royal College of Nursing guidance.
  • Ensure staff recruitment records include all relevant information.
  • Continue to develop a record of staff immunisation status for all diseases recommended by Public Health England.
  • Improve quality improvement methods such as completion of full-cycle clinical audits to monitor and improve patient outcomes.
  • Put a clear vision and set of values in place to support high quality care.
  • Improve governance procedures to ensure that risks, issues and performance concerns are identified and managed effectively.

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

23 February and 7 March 2018

During a routine inspection

We previously carried out an announced comprehensive inspection at The Beechdale Surgery in May 2017. The overall rating for the practice was inadequate.

We carried out a focused inspection in December 2017 to confirm that the practice had taken the required action to meet the legal requirements in relation to the breaches in regulation set out in warning notices issued to the provider following our May 2017 inspection. The warning notices were issued in respect of breaches of regulation related to safe care and treatment and good governance.

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

This inspection was a comprehensive inspection with a site visit undertaken on 23 February 2018. The Beechdale Surgery is one of four locations of the provider ‘The Beechdale Medical Group’, All four locations were inspected between 22 February 2018 and 7 March 2018. The overall rating for this location is good.

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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

Our key findings were as follows:

  • The practice had implemented clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. Robust recording systems had been introduced to ensure significant events were monitored and reviewed.
  • Arrangements to respond to emergencies had been significantly improved; arrangements had been standardised across the practice group.
  • Regular risk assessments were undertaken including risk assessments in respect of fire and legionella.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff were supported to access the training required to fulfil their roles and received regular appraisals.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Leadership arrangements had been reviewed and improved across the practice group; this included the recruitment of a new business manager to provide strategic and operational leadership.

However, there were also areas of practice where the provider should make improvements.

The provider should:

  • Improve and review the system to record the immunisation status of relevant staff members in line with guidance
  • Continue to review and improve uptake rates for cancer screening
  • Continue to improve the use of the clinical system to ensure all tasks are managed appropriately

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 December 2017

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 Beechdale Surgery on 11 May 2017 and 23 May 2017. The overall rating for the practice was inadequate. The full comprehensive report from May 2017 can be found by selecting the ‘all reports’ link for The Beechdale Surgery on our website at www.cqc.org.uk.

The overall rating of inadequate will remain unchanged until we undertake a further full comprehensive inspection of the practice within the six months of the publication date of the report from May 2017.

This inspection was a focused inspection carried out on 1 December 2017 to confirm that the practice had taken the required action to meet the legal requirements in relation to the breaches in regulation set out in warning notices issued to the provider. The warning notices were issued in respect of breaches of regulation related to safe care and treatment and good governance.

Our key findings were as follows:

  • The practice had complied with the warning notices we issued and had taken the action needed to comply with legal requirements.
  • Arrangements to handle emergencies had been improved.
  • Arrangements to dispose of sharps waste had been improved.
  • New systems had been introduced to ensure staff were provided with the training relevant to their role.
  • Systems to identify, monitor and mitigate risk had been improved in respect of risks related to fire and legionella.
  • Systems to monitor access to appointments had been improved and there was additional GP capacity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 May 2017 and 23 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Beechdale Surgery on 11 May 2017 and 23 May 2017. Overall the practice is rated as inadequate.

The Beechdale Surgery is a registered location under the provider, The Beechdale Medical Group. All of the registered locations within the Beechdale Medical Group were inspected on 11 and 23 May 2017; all four locations have been rated inadequate for the well-led domain.

The Beechdale Surgery was previously inspected in November 2014 and rated as good in all domains.

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. However, systems for the management of significant events needed to be strengthened to ensure these were documented properly, learning was identified and shared and events were reviewed.
  • Some risks to patients were assessed and well managed; however the practice had not appropriately identified and assessed all risks. For example, those relating to recruitment checks, fire risk and legionella.
  • During our inspection we identified issues related to the disposal of sharps waste.
  • Not all staff were aware of the location of emergency medicines and non-clinical staff had not undertaken cardio-pulmonary resuscitation training since 2014.
  • Staff were aware of evidence based guidance.
  • Data showed patient outcomes were in line with or above the local and national averages for most indicators. However, data provided by the practice indicated that there were 56 patients on their QOF learning disability register. However, only three of these patients had received a review in the last year.
  • Patients said they were treated with compassion, dignity and respect.
  • Services were provided across the practice group form four registered locations with appointments offered seven days per week. Registered patients could access appointments at any location but feedback from patients indicated the system for making appointments at other sites was not always operated effectively.
  • We saw evidence of limited GP appointments at Beechdale Surgery on certain days. This meant patients would have to travel to other sites to access GP services.
  • There was limited evidence to demonstrate that learning from complaints was identified and shared with staff.
  • The practice had a number of policies and procedures to govern activity, but some of these needed to be reviewed to ensure they were relevant to all sites.

The areas where the provider must make improvements are:

  • Ensure systems and processes for reporting, recording, acting on and monitoring significant events, incidents and near misses and operated effectively.
  • Ensure arrangements are in place to provide safe care and treatment including taking appropriate action in the event of a clinical or medical emergency and ensuring that sharps waste is disposed of in line with guidance.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure systems are operated effectively to assess, monitor and mitigate risk including fire risk and risk of legionella.
  • Ensure staff are supported to undertake training defined as mandatory by the provider

In addition the provider should:

  • Provide staff with regular performance appraisals.
  • Improve arrangements to seek and act on feedback from all staff
  • Review the arrangements for the storage of vaccines
  • Ensure complaints are handled in line with practice policy and that learning from complaints is documented and shared with relevant staff
  • Review and improve arrangements for undertaking annual reviews of patients with a learning disability

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Beechdale Surgery offers a range of primary medical services from a single surgery at 439 Beechdale Road, Nottingham.

Prior to our inspection we consulted with the local clinical commissioning group (CCG) and the NHS local area team about the practice. A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services. Neither of these organisations had any significant concerns.

We carried out an announced inspection on 5 November 2014.

During the inspection we spoke with patients and carers that used the practice and met with members of the patient reference group(PRG). A PRG is a group of patients who have volunteered to represent patients' views and concerns and are seen as an effective way for patients and GP surgeries to work together to improve services and to promote health and improved quality of care.

We also reviewed comments cards that had been provided by CQC on which patients could record their views.

We looked at patient care across the following population groups: Older people; those with long term medical conditions; mothers, babies, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health.

Our key findings were as follows:

  • Patients of Beechdale Surgery were unanimously positive in their praise of the care and empathy shown by both clinical and non clinical staff and told us of several examples of where the staff had gone above and beyond what would normally be expected to support people in their everyday care and at times of crisis and bereavement.
  • We found that practice was proactive in reaching out to people in particularly difficult situations, for example patients involved in drug and alcohol misuse and to patients with severe neurological conditions. The partner GP held this area of medicine as one of particular interest and worked with several agencies to meet the primary health care needs of these groups of patients as well as those suffering from mental health problems and took a prominent role in suicide prevention initiatives.
  • The practice put care, compassion and continuity of healthcare as their primary objective.
  • Patients were cared for in a safe and clean environment by staff who were appropriately qualified and supported.
  • Patients we had contact with were unanimous in their endorsement of the care and treatment they received and said they were fully involved in decisions about their care.

The overall rating for Beechdale Surgery is 'Good'.

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

The provider should:

  • Have in place a process to record all verbal complaints to ensure that any recurring themes can be identified and acted upon.
  • Develop and implement the on-line appointment booking system to widen the opportunity for patients to book consultations at a time that best suited them.
  • Ensure that all the required checks are carried out prior to staff taking up a post.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice