Home / Sources / CQC / Billet Lane Medical Practice
Index live
Source · CQC inspection

Billet Lane Medical Practice

Type Primary Medical Services Region London Last inspected 20 Jul 2023

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

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
RatingRequires Improvement
TypeComprehensive 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