St Andrews House Medical Centre

We carried out an announced inspection at St Andrews House Medical Centre on 21 July 2022. Overall, the practice is rated as good.

The key questions are rated as:

Safe - Requires improvement

Effective – Good

Caring - Good (rating awarded at the inspection June 2016)

Responsive - Good (rating awarded at the inspection June 2016)

Well-led – Good

The provider was last inspected June 2016 and was rated Good overall and in all of the key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Andrews House Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. This included focusing on the key questions safe, effective and well led. Caring and responsive were not inspected.

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 by telephone and 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
• Gaining feedback from staff using staff questionnaires
• A shorter 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

We found that:

• The practice in the main 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.
• 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

Following this inspection, we have rated the practice requires improvement for providing safe services. The practice did not have effective systems in place for the appropriate and safe use of medicines. Following the inspection the practice provided details of the action they planned to take to improve, for example, they have developed a management plan to address concerns raised in safe, which included developing an overarching governance systems to monitor the safe use of medicines.

We found one breaches of regulations. The provider must:

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

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

• Monitor the additional protected learning session set up to enable staff to complete mandatory training and training required to maintain and develop clinical competences.
• Work with staff to develop a shared approach to communication.
• Formalise process to ensure regular consultations audits are completed to assess ongoing clinical competences.

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