Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beversbrook Medical Centre on 26 January 2016. Overall the practice is rated as requires improvement.

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 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.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• 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.

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

• The practice must improve their systems for learning from significant events, audits, complaints and patient and staff feedback, and for sharing this learning across the whole practice team.

• The practice must improve the process for reviewing quality indicators. There were no systematic processes in place or evidence to demonstrate that clinical audit was driving improvement and improving patient outcomes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

When we visited Beversbrook Medical Centre on 26 January 2016 to carry out a comprehensive inspection, we found the practice was not compliant with the regulation relating to good governance. Overall the practice was rated as requires improvement.

We found the practice requires improvement for the provision of effective and well-led services because there were no clear systems for monitoring and learning from significant events, clinical audits, performance data, complaints, or patient and staff feedback. The practice could not use this information to improve performance and patient outcomes.

Following the inspection the provider sent us an action plan that set out the changes they would make and subsequently supplied information to confirm they had completed the actions.

This focused inspection was undertaken to ensure that the practice was meeting the regulation previously breached. For this reason we have only rated the location for the key questions to which this related. This report should be read in conjunction with the full report of our inspection on 26 January 2016, which can be found on our website at www.cqc.org.uk.

Overall the practice is now rated as Good.

Our key findings were as follows:

• The practice had implemented a significant event policy setting out how to report significant events. We saw a log in which the practice recorded and checked actions that had been taken and minutes of management meetings where significant events had been discussed and learning points identified.  

• The practice told us that all complaints were also treated as significant events and we saw evidence to confirm this.

• We saw from minutes of meetings that the practice was regularly reviewing it’s performance and quality outcomes framework data, and where appropriate making changes to how they worked in order to improve their performance.

• The practice had an audit plan which showed nine clinical audits had been conducted in the last year.

• The practice had a weekly newsletter. This was used to update staff on a wide range of issues. We saw examples of where they had used this to share learning from safeguarding and significant events, provide updates on new guidance and procedures, and gave information on audits as well as a range of other topics.

• There was evidence the practice

  encouraged and valued feedback from patients, the public and staff, which it used to help improve services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice