The Care Quality Commission
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  • GP practice

Archived: Burnham & Berrow Medical Centre

Overall: Inadequate read more about inspection ratings

Love Lane, Burnham On Sea, Somerset, TA8 1EU (01278) 795445

Provided and run by:
Burnham & Berrow Medical Centre

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

All Inspections

15 November 2022

During an inspection looking at part of the service

Previously we carried out an announced comprehensive inspection on 28 July and 1 August 2022. We applied urgent conditions to the provider registration of Burnham & Berrow Medical Centre. The conditions focused on reviewing patients’ care and treatment; clearing the backlog of unactioned tasks and correspondence; ensuring all significant events raised in practice were reviewed, necessary action taken and learning shared with practice staff. This was in relation to the significant concerns identified relating to patient safety and leadership and governance.

Additionally we served warning notices on the provider for breaches of Regulation 17 Good Governance and Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulation Activities) Regulations 2014 because the quality of care they are responsible for fell below expected standards and legal requirements.

We carried out an announced focused inspection at Burnham & Berrow Medical Centre on 15 November 2022 to confirm that the practice had met the legal requirements in relation to the conditions placed on their registration and the warning notices issued. We did not rate this inspection. The rating of inadequate and special measures period remains in place until we undertake a full comprehensive inspection.

At this inspection, we found that improvements had been made and the practice had met the requirements in relation to the conditions and warning notices issued.

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

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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 found that:

  • Processes to support the management of tasks and workflow of documents had improved. The practice had reduced the backlog of unfiled documents and had implemented a protocol to support the timely review of test results.
  • The provider had introduced a medicines safety protocol for patients with overdue monitoring.
  • Regular audits were conducted on the prescribing of high risk medicines and the number of medicine reviews conducted.
  • Processes to support the review of significant events had improved. All significant events previously identified had received a review.
  • The practice had improved monitoring of patients with long term conditions and had prioritised patients most at risk.
  • Staff competencies had been reviewed and training requirements identified.

The areas where the provider should make improvements are:

  • Implement practice specific guidance on safeguarding processes and ensure information is disseminated among necessary staff.
  • Review processes to ensure patients affected by safety alerts are identified and appropriate actions are taken.
  • Implement processes to formally supervise staff employed in advanced clinical practice.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

28 July 2022 and 1 August 2022

During a routine inspection

We carried out an announced comprehensive inspection at Burnham & Berrow Medical Centre on 28 July and 1 August 2022. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Caring - Requires Improvement

Responsive - Inadequate

Well-led - Inadequate

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.

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 found that:

  • The practice systems, practices and processes to keep people safe and safeguarded from abuse, were not always embedded.
  • The practice did not have a system to learn and make improvements when things went wrong.
  • The practice did not have effective systems for the appropriate and safe use of medicines.
  • Management of people with long term conditions was not effective.
  • The practice was unable to demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
  • Staff did not always treat patients with kindness, respect and compassion. Feedback from patients was mixed about the way staff treated people.
  • Services did not always meet patients’ needs.
  • People were not always able to access care and treatment in a timely way.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
  • The overall governance arrangements were ineffective.

Following the inspection, we applied urgent conditions to the provider registration of Burnham & Berrow Medical Centre. The conditions focused on reviewing patients’ care and treatment; clearing the backlog of unactioned tasks and correspondence; ensuring all significant events raised in practice were reviewed, necessary action taken and learning shared with practice staff. This was in relation to the significant concerns identified relating to patient safety and leadership and governance.

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 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 vary the provider’s registration 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.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Ensure recruitment files for locum staff working for the practice contain necessary information.
  • Ensure statutory notifications are submitted to the Care Quality Commission in line with requirements.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

24 August 2021

During a routine inspection

We carried out an announced inspection at Burnham and Berrow Medical Centre on 24 August 2021. Overall, the practice is rated as requires improvement.

The ratings for each key question are:

Safe - Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive – Requires Improvement

Well-led – Requires Improvement

Following our previous inspection on 11 May 2017 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 Burnham and Berrow Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in response to an increase in intelligence indicating a potential decline in performance of this practice and an escalation of risk. This inspection was a comprehensive inspection where we inspected all five key questions, Safe, Effective, Caring, Responsive and Well-led.

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, with Good in caring and Requires Improvement for safe, effective, responsive and well-led key questions. We have rated all the population groups as Requires Improvement overall. This is because the feedback highlighted in the national GP patient survey report regarding accessing the service, affects all patients in all of the population groups.

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected from avoidable harm. Not all patients on high risk medicines were appropriately monitored or recalled.
  • Patients did not always receive effective care and treatment that met their needs. Action had been taken to improve patient outcomes in relation to the Quality Outcomes Framework. However, the performance indicators in relation to the majority of long term conditions were below the national average.
  • 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.
  • There were significant constraints on the ability of people to access care and treatment in a timely way using the telephone system.
  • The leadership and governance did not always support the delivery of high-quality person-centred care, which led to safety concerns and inconsistencies in record keeping for example, recruitment processes, fire safety and health and safety systems.

We also found the following areas of notable practice:

  • Patient feedback was positive about the COVID-19 vaccination programme and the way it had been managed and delivered.
  • During the pandemic the practice had run Young Adult and Family Planning Clinics via telephone, as well as face to face appointments for patients who needed to be seen. A member of the nursing team had researched and developed a policy for the provision of self-administered long action contraceptive injections. Patients therefore only needed to attend the practice once a year for review, rather than every 13 weeks.

We found two breaches of regulations. The provider must:

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

The areas where the provider should make improvements are:

  • Ensure systems for the disposal of clinical waste, in respect of sharps bins are reviewed and embedded into practice.
  • Continue to monitor and improve outcomes for patients with long-term conditions.
  • Continue to identify ways to improve uptake for cervical screening.
  • Continue to monitor and improve outcomes for patients with mental health conditions.
  • Ensure all staff receive an annual appraisal.
  • Establish an effective Patient Participation Group.
  • Ensure patient surveys are embedded into continuous improvement processes.

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

12 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice


We carried out an announced follow-up inspection at Burnham & Berrow Medical Centre on 12 April 2017 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 and to check if improvements had been made in response to our previous comprehensive inspection on 22 June 2016.

On 22 June 2016 we found the practice required improvement in the safe domain and was rated by us as good for effective, caring, responsive and well-led domains. The overall rating for the practice was good. We issued a requirement notice with regards to the breach of Regulation 12 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Safe care and treatment. The requirement notice was for the provider to make improvements to ensure:

  • Patient Group Directions (PGD) that had been adopted by the practice to allow nurses to administer medicines were appropriately authorised to allow individual named health professionals to practise under the PGD.
  • Fridges that were used to store medicines were subject to safe storage procedures to ensure that vaccines were stored within the appropriate temperature range and a cold chain maintained.
  • All blood test results were to be viewed by a GP in a timely way in order to do all that is reasonably practicable to mitigate the related risks.
  • Necessary actions were to be taken to identify and record risks regarding the absence of paediatric defibrillator pads at Berrow Medical Centre.

In addition we told the provider they should:

  • Improve the care planning for patients experiencing poor mental health (including people with dementia) by incorporating information from the relevant mental health team as well as the activity of the practice into individual care plans.
  • Review and follow practice policy regarding recruitment checks prior to employment of new staff.

The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Burnham & Berrow Medical Centre on our website at www.cqc.org.uk.

Overall the practice is now rated as Good.

Our key findings across the areas we inspected on 12 April 2017 were as follows:

  • Patient Group Directions (PGD) that had been adopted by the practice to allow nurses to administer medicines were appropriately authorised to allow individual named health professionals to practise under the PGD.
  • Fridges that were used to store medicines were subject to safe storage procedures to ensure that vaccines were stored within the appropriate temperature range and a cold chain maintained.
  • All blood test results were viewed by a GP in a timely way in order to do all that is reasonably practicable to mitigate the related risks.
  • Necessary action had been taken to identify and record risks regarding the use of defibrillator pads for life-threatening abnormal heart rhythms.
  • Systems were in place to code and incorporate care plans for patients experiencing poor mental health (including people with dementia) into patient records.
  • There was a system to ensure appropriate recruitment checks such as references had been undertaken prior to employment.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22nd June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Burnham & Berrow Medical Centre on 22nd June 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.
  • 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.
  • 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 practice had strong and visible clinical and managerial leadership and governance arrangements. For example, staff told us the partners were very accessible, listened to concerns and implemented change process to improve the quality of the service.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had identified 620 patients as carers (nearly 4% of the practice list). The practice had five Carers Champions who provided help and support for the practice’s registered carers and provided a link between them and practice’s health care professionals.
  • Two of the practice’s younger members of staff had a role of Young Carers Support leads, in order to better engage with young people who may not recognize themselves as a carer. Young Carers had their own information leaflet which were on display in their Young Adults Clinic.

We saw one area of outstanding practice:

  • The practice ran a Young Adult Drop-in-Clinic which was provided for 13 to 20 year olds and was not limited to practice patients. The practice understood that many young people may experience anxiety when accessing health services. The clinic made efforts to make sure that it met the needs of the local young people and had had good communication with the local school to ensure students were referred appropriately. Patients could discuss sexual health and also other health or social issues such as, bullying, smoking and diet.

The areas where the provider must make improvement are:

  • Patient Group Directions that had been adopted by the practice to allow nurses to administer medicines in line with legislation must be signed by the GP as the appropriate person authorising individual named health professionals to practise under the PGD and/or the named individual health professionals who are to practise under the PGD.
  • The temperatures of the fridges that were used to store medicines must be checked daily to ensure that medicines were stored within the appropriate temperature range.
  • The practice must identify and record the risks regarding the absence of paediatric defibrillator pads at Berrow Medical Centre and take the necessary actions to manage any identified risks.
  • The practice must ensure that blood test results are viewed by a GP in a timely way in order to do all that is reasonably practicable to mitigate the related risks.

The areas where the provider should make improvements are:

  • The practice should improve the care planning aspect for patients with mental health needs by incorporating information from the relevant mental health team as well as the activity of the practice.
  • The practice must ensure that practice policy recruitment checks had been undertaken prior to employment of new staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 January 2014

During a routine inspection

We visited both the Burnham on Sea and Berrow sites and met with staff and patients. We heard from staff the service was well led and 'had good team work, everyone is valued.' Patients we spoke with all told us they would recommend the surgery to other patients. We heard 'the doctor was very nice and listened to me."

We read the audits of clinical practice which the surgery undertook to ensure the treatment was effective for patients. Patients told us 'the telephone triage system means I can have a telephone consultation with the GP, and sometimes this is enough.'

We found the practice had processes in place which kept patients safe and protected them against abuse. The surgery had equipment available to support patients in an emergency.

Patients told us the surgery was responsive to their needs. We were told 'I had an emergency, so I phoned up and got an appointment straight away.' We were also told 'I was referred for specialist care and I didn't have to wait any time at all.' We saw there were processes in place which assessed the quality of the service and allowed change to be implemented when needed.