Bigham Road Medical Centre

We carried out an announced inspection at Bigham Road Medical Centre on 6 and 12 April 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires improvement

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

Why we carried out this inspection

This inspection was a comprehensive review following registration with CQC in September 2019.

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 Good overall

We found that:

• The practice had systems, practices and processes to keep people safe and safeguarded from abuse.
• Effective measures were in place to minimise the risk presented by the Covid-19 pandemic.
• 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.

Well-led has been rated as requires improvement because:

• The providers existing systems and processes did not always adequately identify risks and in some cases relied on external parties to identify them before they were addressed.
• Not all staff had completed the relevant training for their role.
• Recruitment files did not contain all of the required evidence, to be kept.The practice did not have a programme of quality improvement and audit in place and patient records were not always fully documented.

We found one breach of regulation. The provider must:

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

The provider should:

• Continue to monitor the uptake of cervical screening programme and children’s vaccination.
• Capture themes from informal feedback patients provide.
• Share details of Freedom to Speak up Guardians with staff.

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