The Care Quality Commission
  • Doctor
  • GP practice

HMC Health Bedfont

Overall: Good read more about inspection ratings

Imperial Road, Feltham, Middlesex, TW14 8AG (020) 8890 2245

Provided and run by:
Hounslow Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about HMC Health Bedfont on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about HMC Health Bedfont, you can give feedback on this service.

13 July 2022

During an inspection looking at part of the service

We carried out an announced focused review at HMC Health Bedfont on 13 July 2022. Overall, the practice is rated as Good.

Safe - Good.

Effective - Not inspected, rating of good carried forward from previous inspection.

Caring - Not inspected, rating of good carried forward from previous inspection.

Responsive - Not inspected, rating of good carried forward from previous inspection.

Well-led - Not inspected, rating of good carried forward from previous inspection.

Following our previous inspection in September 2021, the practice was rated good overall and for all key questions but requires improvement for providing safe services.

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

Why we carried out this review

This was a focused review of information without undertaking a site visit inspection to follow up on breaches of Regulation 12 Safe care and treatment. At the last inspection we found;

  • The practice had a system in place to manage safety alerts but it did not work effectively as we found some safety alerts were not actioned as required to ensure the safe care and treatment of patients.

We also followed up on ‘should’ actions identified at the last inspection. Specifically;

  • Take action to ensure the prescription box for uncollected prescriptions is monitored regularly and staff members understand their responsibilities to take appropriate steps as and when required.
  • Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake.
  • Continue to make efforts to establish the patient participation group (PPG).

How we carried out the 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 review was carried out without visiting the location by requesting documentary evidence from the provider.

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 had made the necessary improvements to the delivery of care to ensure patients were kept safe.
  • The practice had improved the system for recording and acting on safety alerts. The practice carried out regular audits to ensure that all current and future patients were reviewed accordingly. The practice had shared the recent clinical data which demonstrated improvements in patient outcomes.

In addition;

  • The practice had implemented monthly uncollected repeat prescriptions checks. The practice informed us that they would contact the patients’ to check if they still required the medication or if a new prescription was issued.
  • The practice had taken steps to improve childhood immunisation uptake. The practice had maintained a register and dedicated staff members who were part of the organisation recall team were contacting the parents or guardians of children and encouraging childhood immunisation uptake. The practice was carrying out weekly searches to monitor the performance. The practice had arrangements for following up on failed attendance of children’s appointments for immunisation.
  • The practice had taken steps to encourage uptake. For example, there was a policy to offer telephone reminders and send text messages to patients who did not attend for their cervical screening test. All non-attendance was flagged on the patient’s record so that the clinicians opportunistically encouraged patients to make their appointments. The practice had shared recent Quality Outcomes Framework (QOF) results and informed us they had achieved 73% cervical cancer screening rates for patients aged 25-49 years and 85% screening rates for patients aged 50-64 years old.
  • The practice informed us they had tried but were not successful in establishing the patient participation group (PPG). The practice had sent text messages and displayed posters in the waiting area encouraging patients to join the PPG. The practice was planning a patient engagement event in September 2022.

Whilst we found no breaches of regulations, the provider should:

  • Continue to make efforts to establish the patient participation group (PPG).

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

21, 22 and 23 September 2021

During an inspection looking at part of the service

We carried out an announced inspection at HMC Health Bedfont on 21, 22 and 23 September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Good

Well-led - Good

Following our previous inspection on 20 January 2020, the practice was rated Requires Improvement overall and for providing safe and effective services. The practice was rated Good for caring, responsive and well-led key questions:

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 18 Staffing.

At this inspection we covered the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services well-led?

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.
  • 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 and Good for all population groups, with the exception of working age people (including those recently retired and students), which is rated as requires improvement. We rated the practice as requires improvement for providing safe services.

We found that:

  • The practice had demonstrated improvements in governance arrangements compared to the previous inspection.
  • The practice had a system in place to manage safety alerts, however it did not work effectively as we found some safety alerts were not actioned as required to ensure the safe care and treatment of patients.
  • We found the prescription box for uncollected prescriptions was not monitored effectively.
  • 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. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Take action to ensure the prescription box for uncollected prescriptions is monitored regularly and staff members understand their responsibilities to take appropriate steps as and when required.
  • Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake.
  • Continue to make efforts to establish the patient participation group (PPG).

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

20 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at HMC Health Bedfont on 20 January 2020 as part of our inspection programme.

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 and requires improvement overall for all population groups.

We rated the practice as r equires improvement for providing safe and effective services because:

  • Risk to patients were assessed and well managed in some areas, with the exception of those relating to the fire safety procedures, recruitment checks, emergency medicines and staff vaccinations.
  • The practice was unable to demonstrate that all clinical staff had received annual appraisals, and childhood immunisations and travel immunisations training updates. Not all staff had received formal clinical supervision on a regular basis.
  • The practice’s uptake of the national screening programme for cervical cancer screening rates were below the national average.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.

We rated the practice as good for providing caring, responsive and well-led services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • Feedback from patients reflected that they were able to access care and treatment in a timely way.
  • A hearing induction loop and baby changing facilities were not available on the premises, and the conversations could be heard in the adjacent clinical rooms.
  • Information about services and how to complain was available.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • There was a clear leadership structure and staff felt supported by the management.
  • The practice had demonstrated good governance in most areas, however, they were required to make some improvements.

We rated all population groups as good for providing responsive services. We rated all population groups as requires improvement for providing effective services, because we found concerns about staff appraisal, training and supervision, and low cervical cancer screening rates.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake.
  • Take action to ensure the practice takes into account the needs of patients with hearing difficulties and baby changing facilities.
  • Review and update the policies, and ensure relevant policies are signed off by a clinical lead.
  • Continue to make efforts to establish the patient participation group (PPG).
  • Improve soundproofing in the adjacent clinical rooms.
  • Take necessary action to resolve the CQC registration issues.

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