17 and 23 May 2023
During an inspection looking at part of the service
We carried out an announced comprehensive at Belgrave Medical Centre (also known as The Matthews Practice) on 17 and 23 May 2023. Overall, the practice is rated good. The practice had made improvements to the management of long term conditions. However, attainment in relation to childhood immunisations and cervical screening is still lower than target rates and had not improved since our last inspection.
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good`
Following our previous inspection on 17 and 21 September 2021, the practice was rated good overall and for safe, caring, responsive and well led services. The practice was rated requires improvement for effective services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Belgrave Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up on shoulds identified from a previous inspection in September 2021:
- Continue to improve the uptake of childhood immunisations and cervical cancer screening.
- Lower than average attainment in relation to the management of some long term conditions.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing and face to face.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- Reviewing staff feedback forms.
- Reviewing PPG feedback forms.
- Speaking with patients.
- 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 found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- 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.
- Patients could access care and treatment in a timely way. The practice were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to people who use services. For example a diabetes support group and a menopause initiative.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Leaders had an inspiring shared purpose, and strove to deliver and motivate staff to succeed.
Whilst we found no breaches of regulations, the provider should:
- Continue with plans to improve childhood immunisations and uptake of national screening programmes.
- Implement and embed systems for monitoring the effectiveness of the care, treatment and support people with long term conditions receive.
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