The Bethesda Medical Center has been rated as Requires Improvement following an inspection by the Care Quality Commission (CQC).
The inspection was carried out in February with the report published this month. The overall rating was Requires Improvement, a fall from the 2015 rating of Good.
Key area ratings were:
- Safe – Requires Improvement
- Effective – Good
- Caring – Not inspected
- Responsive – Inspected but not rated
- Well-led – Requires Improvement
The Requires Improvement grading for providing safe services was due to inspectors finding that audits of infection prevention and control were not sufficient; vaccines were not always appropriately stored and monitored; the practice did not have an effective system for monitoring significant events and ensuring that actions to improve safety had been implemented and blank prescriptions were not kept securely.
The requires improvement grading for providing well-led services was due to leaders lacking oversight of some processes and failing to identify risks when those processes did not operate as intended.
Inspectors found two breaches of regulations.
However, they also found that patients received effective care and treatment that met their needs; 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 and staff had the training and skills required for their role.
Bethesda Medical Center must now ensure safe care and treatment and establish effective systems and processes to ensure good governance.
The CQC said Bethesda should also:
- Maintain an up to date safeguarding register.
- Ensure records are kept of monthly checks of emergency equipment.
- Ensure patients with long term conditions receive up to date monitoring, in particular those with hypothyroidism and chronic kidney disease.
- Improve childhood immunisation rates so that the minimum 90% target is met for all five indicators.
- Improve cervical screening rates so that the Public Health England 80% coverage target is met.
- Develop a formal program of targeted audit and quality improvements.
- Continue to review patient access and ease of getting through on the phone.
- Consider practice holding meetings that include all staff.
- Consider holding multi-professional meetings to aid communication and enable the sharing of good practice.
The Palm Bay Avenue surgery has a patient population of about 19,600. The practice is part of a wider group of four GP practices which form the Margate primary care network.
There are four GP partners and five salaried GPs and a medical director. The practice has an acute care team with two paramedic practitioners, two nurse practitioners and a paediatric nurse practitioner.
There is a practice nurse team comprising six practice nurses and five healthcare assistants and a clinical pharmacist. The practice also has a team of care co-ordinators with three frailty co-ordinators, one community health co-ordinator and a social prescribing link worker. There are three mental health nurses that are employed via the primary care network plus a team of administration and reception staff led by the practice manager.