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Billet Lane Medical Practice

Type Primary Medical Services Region London Last inspected 20 Jul 2023

Location rating: Requires Improvement  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location, last inspected 20 July 2023. Ratings extracted from individual reports are shown separately below.

Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Comprehensive inspection
Date: 20 July 2023
Rating extracted from this report: Requires Improvement
Actions indexed: 2 must-do 4 should-do

Read this inspection PDF

AI-extracted 17 Feb 2026

Earlier inspection findings

pre-2024 framework · 2 must-do 4 should-do

Must-do actions (2)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 2
Must do
Safe
Ensurecareandtreatmentisprovidedinasafewaytopatients.
Regulation: 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 action 2 of 2
Must do
Well-led
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcare.
Regulation: 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 action 1 of 4
Should do
Safe
Improveandformalisethemonitoringofthechildren'ssafeguardingregister.
Should-do action 2 of 4
Should do
Well-led
Takeactiontorecordthereviewsofsignificanteventsatclinicalmeetingsandcompleteasignificanteventlog.
Should-do action 3 of 4
Should do
Effective
Continuetoimprovestaffuptakeoftrainingandthepracticesassuranceofstaffcompetenciesfortheirroles.
Should-do action 4 of 4
Should do
Effective
Improvescheduleofclinicalauditstomonitorandimprovepatient'sclinicalcare.demonstrateaqualityservice.

Previous inspection

24 August 2022
Rating extracted from this reportRequires Improvement
TypeComprehensive inspection
Actions 3 must-do 3 should-do

Read previous inspection PDF

2 resolved 3 repeated 1 partial