Archived: Becontree Medical Centre

We carried out an announced inspection at Becontree Medical Centre on 08/09/10 and 19 August 2022. This is the first inspection under this provider registration and it is a rated inspection.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Asma Moghal, the previous registered provider, on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection, including undertaking a site visit.

How we carried out the inspection/review

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 Inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice did not have reliable systems and processes to keep patients safeguarded from abuse.
• The practice did not have a safe system in place to manage safeguarding including training for staff.
• The practice did not have a safe system in place to monitor and manage recruitment, including disclosure and barring checks (DBS).
• The practice did not have appropriate systems in place to safely manage high-risk medicines and medicines that require additional monitoring.
• The practice did not have a safe effective system in place to manage patient safety alerts.
• The practice did not operate a safe system regarding staff immunisations and certified immunity.
• The practice did not have a safe effective system in place to safely manage emergency medicines.
• The practice did not have reliable systems in place to manage the practice premises safely.
• There was no failsafe process in place to follow-up patients who have been referred by the two-week wait urgent referral system and who undertaken cervical screening.
• Not all significant events had been recorded.

We rated the practice as inadequate for providing effective services because:

• Clinical care was not delivered consistently in line with national guidance.
• There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• The practice did not operate an effective system regarding clinical supervision and clinical protocols.
• Some performance data was significantly below expected achievement averages.

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

• A deterioration over time in the National GP Patient Survey results regarding the key question for Caring.
• Staff did not have oversight of and could not tell us how many carers were present in their practice population.
• There was evidence that staff treated patients with kindness, care and compassion.
• There was evidence to show how the practice carried out patient surveys and patient feedback exercises.

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

• A deterioration over time in the National GP Patient Survey results regarding the key question for Responsive.
• Access to sufficient appointments was a consistent issue for patients.

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

• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• The practice culture did not effectively support high quality sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We saw limited evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

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

The provider should:

• Develop a system for regular review of practice policies.

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

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.

Dr Sean O’Kelly

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