Billet Lane Medical Practice

Primary Medical Services · London

Overall Rating
Requires Improvement Last inspected 20 July 2023
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

View Full CQC Report

2 must-do actions
4 should-do actions

Must-Do Actions (2)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
Ensurecareandtreatmentisprovidedinasafewaytopatients.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Theregisteredpersonshadnotdoneallthatwasreasonablypracticabletomitigateriskstothehealthand safetyofserviceusersreceivingcareandtreatment.Inparticular: • Thepracticedidnotidentifypatientsandtakeactionin responsetoamedicinessafetyalertsuchas(MHRA) alerts. • Thepracticesystemtomonitorthegroupofmedicines usedtotreathighbloodpressure,heartproblems,and anticoagulantswasnotalwayseffective. • Somepatientmentalhealthreviewsdidnothaveclear evidencethatanannualcareplanhadbeenfully completed. • Somepatients'recordswereunclearanddidnotfully explainthereasonsfortheirtreatment.Forexample, medicinereviewsandlong-termtreatmentplans. • Thepracticedidnothavetheappropriateemergency medicines.
Must Do
Well-led
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcare.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
Theregisteredpersonhadsystemsorprocessesinplace thatoperatedineffectivelyinthattheyfailedtoenablethe registeredpersontoassess,monitorandimprovethe qualityandsafetyoftheservicesbeingprovided.In particular: • Thesystemsinplaceforsaferecruitment,actionon safetyalerts,patientreferrals,andthesafemonitoring ofmedicineswerenotalwayseffective. • Thepracticedidnotcarryouttheirownpatientsurvey. • Thepracticesdidnotensurepatientshadprompt accesstothepractice.

Should-Do Actions (4)

Recommended improvements to enhance service quality.

Should Do
Safe
Improveandformalisethemonitoringofthechildren'ssafeguardingregister.
Should Do
Well-led
Takeactiontorecordthereviewsofsignificanteventsatclinicalmeetingsandcompleteasignificanteventlog.
Should Do
Effective
Continuetoimprovestaffuptakeoftrainingandthepracticesassuranceofstaffcompetenciesfortheirroles.
Should Do
Effective
Improvescheduleofclinicalauditstomonitorandimprovepatient'sclinicalcare.demonstrateaqualityservice.

Previous Inspection (24 August 2022)

Rating: Requires Improvement Type: Comprehensive inspection Actions: 3 must-do , 3 should-do
2 resolved 3 repeated 1 partial
Location Details
CQC ID: 1-10324365409
Local Authority: Havering
Region: London
Inspection Report
Type: Comprehensive inspection
Date: 20 July 2023
Rating: Requires Improvement
Actions: 2 must-do , 4 should-do
AI-extracted 17 Feb 2026