The Beeches Medical Centre

We carried out an announced inspection at The Beeches Medical Centre on 1 June 2022. Overall, the practice is rated as Requires Improvement.

We rated each key question as follows:

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires Improvement

Following our previous inspection on 20 April 2018, the practice was rated Good overall and for all key questions. However, this was a previous registration and the service inherited the rating when it changed hands.

Following this inspection, we issued a warning notice for a breach of regulation 12. However, subsequent additional evidence was supplied by the service which they could demonstrate was in place at the time of inspection. Therefore the warning notice had been met at the time of publishing this report.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to provide a rating of the service which was registered on 3 October 2019.

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 and face to face
• Requesting written feedback from staff and patients
• 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 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 rated the practice requires improvement for providing safe services:

We found that:

• Our clinical record searches identified that the practice did not always have oversight of the monitoring of high risk medicines and disease modifying anti-rheumatic drugs (DMARDs). We saw that monitoring was in place in the majority of cases, however we did observe some omissions that were not mitigated and identified some monitoring of creatine clearance had not been undertaken. It was not always evident that blood test results had been checked before medicines were issued.
• The practice did not have an effective system to identify overprescribing of respiratory inhalers in a timely way.
• There were some shortfalls in the recruitment procedures and records.
• Assurance of training in infection prevention and control procedures and outcome from audits could be improved.

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

We found that:

• Improvements were required to the significant event process to facilitate the inclusion of all relevant incidents, with clear outcomes, actions and shared learning.
• Governance systems and oversight of practice management documentation was not evident in some areas, such as the management of practice policies and employment records.
• An effective comprehensive quality monitoring and improvement programme was not in place.

We rated the practice good for providing effective, caring and responsive services:

We found that:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Access to appointments was good. Pre-booked and urgent appointments were available and there was a system in place to prioritise those in greater need. Face to face and telephone appointments were available and patient were usually offered an appointment on the day or the following day in the vast majority of cases.
• The service was responsive to the need of the population it serviced.

We found two breach 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.

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