The Care Quality Commission
  • Doctor
  • GP practice

Trinity Medical Centre

Overall: Requires improvement read more about inspection ratings

2 Garland Road, London, SE18 2AE (020) 8319 7640

Provided and run by:
Dr Maria Coutinho

Important: This service was previously registered at a different address - see old profile

All Inspections

2 November 2021

During a routine inspection

We carried out an announced inspection at Trinity Medical Centre on 2 November 2021. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection on 11 June 2019 the practice was rated Requires Improvement overall and for the safe and effective key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Trinity Medical Centre on our website at www.cqc.org.uk

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.

Part of the inspection was carried out remotely with the intention of us spending 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.

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.
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall and in the safe, effective, responsive and well-led key question.

We found that:

  • Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the target of 90% in two areas where childhood immunisations are measured.
  • Cervical cancer screening was below target for the percentage of women eligible for cervical cancer screening.
  • The practice was above the CCG and England average for the prescribing of hypnotics and for the prescribing antimicrobial prescribing.
  • Staff told us that staffing levels could be improved.
  • Although staff confirmed that cleaning was completed daily, the cleaning checklist did not confirm which areas had been cleaned.
  • We found instances when the provider had not carried out the appropriate monitoring of prescribed medication and patients with long-term conditions.
  • 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.
  • Leaders demonstrated that they understood the challenges to quality and sustainability and had identified the actions necessary to address these challenges.

We found breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Introduce a cleaning schedule to confirm which areas of the practice have been cleaned.
  • Discuss complaints during staff meetings to ensure all staff are informed and lessons are learned.
  • Keep up to date with internal processes such as premises risk assessments.
  • Continue to take steps to address staffing levels and telephone access for patients.

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

11 June 2019

During a routine inspection

CQC carried out an announced comprehensive inspection of Trinity Medical Centre on 4 and 10 October 2018 to follow up on breaches of regulation identified in August 2017. The practice was rated as requires improvement overall with ratings of inadequate for providing safe services, requires improvement for effective and for well led services and good for providing caring and responsive services.

As a result of the findings on the day of the inspection the practice was issued with a warning notice for breach of Regulation 12 (Safe care and treatment) and a requirement notice for Regulation 17 (Good governance). You can read our findings from our last inspections by selecting the ‘all reports’ link for Trinity Medical Centre on our website at .

CQC then carried out an announced focused inspection on 9 January 2019. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements as detailed in the warning notices issued on 16 October 2018.

This was an announced comprehensive inspection carried out on 11 June 2019. This inspection was carried out to follow up on breaches of regulation identified in October 2018.

At the last inspection in October 2018 we rated the practice as inadequate for providing safe services, and requires improvement for providing effective and well-led services because:

  • The practice had no systems in place to monitor patients on high risk medicines.
  • There was no safety netting for patients asked to attend for blood tests.
  • There were no safety netting processes for non-clinical staff members making changes to prescriptions.
  • The provider did not have a copy of the premises’ security risk assessment.
  • There was insufficient information in care plans.
  • Not all children on the at-risk register had flags on their notes.
  • There was no medicines management policy in place or practice protocol for prescribing high risk medicines, which reflected national guidance.
  • The provider did not have an up to date policy or pathology protocol to enable staff to manage test results effectively.

At this inspection, we found that the provider had satisfactorily addressed these areas, however we identified other concerns regarding providing safe and effective services. For example:

  • Systems for security were not fully assessed.
  • There were no emergency medicines in the GP home visit bag, and no risk assessment had been undertaken for not having any.
  • Not all emergency medicines were stocked.
  • There was no process for reviewing non-collected prescriptions.

We have rated this practice as requires improvement overall and requires improvement for people with long-term conditions; and families, children and young people;. All other population groups were rated good.

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 provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients were not always receiving 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 organised and delivered services to meet patients’ needs. 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.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

  • Review and monitor the system for uncollected prescriptions.
  • Review system for undertaking Disclosure and Barring Service (DBS) checks for appropriate staff.
  • Continue to review and undertake quality improvement for patients.
  • Continue to explore and encourage uptake of cancer screening programmes s to improve the uptake of cervical screening and other cancer screenings.

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

09 January 2019

During an inspection looking at part of the service

CQC carried out an announced comprehensive inspection of Trinity Medical Centre on 4 and 10 October 2018 to follow up on breaches of regulation identified in August 2017. The practice was rated as requires improvement overall with ratings of inadequate for providing safe services, requires improvement for effective and for well led services and good for providing caring and responsive services. As a result of the findings on the day of the inspection the practice was issued with a warning notice for breach of Regulation 12 (Safe care and treatment) and a requirement notice for Regulation 17 (Good governance). You can read our findings from our last inspections by selecting the ‘all reports’ link for Trinity Medical Centre on our website at https://www.cqc.org.uk/location/1-4275983140.

This was an announced focused inspection on 9 January 2019. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements as detailed in the warning notices issued on 16 October 2018.

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.

This inspection was an unrated inspection to follow up on warning notices and the rating remains unchanged.

At this inspection we found:

  • The system in place in relation to high risk medicines had been improved. We reviewed records of patients taking high risk medicines and found they had all been monitored appropriately.
  • The practice had started to implement a new process for monitoring and tracking blood test requests and checking patients had attended for their test.
  • The practice had started to implement a new process for managing changes to prescribing.
  • Staff told us the security risk assessment had been carried out on 1 August 2018. However, there was no record of a premises security risk assessment. The building is managed by a private management company who employ a caretaker to secure the building every evening. There was no record that the practice had been made aware of any actions required from the risk assessments. The practice was not able to give us a copy of the security risk assessment at our previous inspection in October 2018.
  • There was a system for flagging children at risk. We saw appropriate coding in patient records.
  • There was no medicines management policy in place or practice protocol for prescribing high risk medicines, which reflected national guidance. There was no safety netting policy or pathology protocol to support staff to manage test results effectively. There was no medicines management policy in place. We saw a repeat prescribing policy.
  • We found the practice had implemented monthly clinical and non-clinical meetings, which were minuted and distributed amongst all staff. The meetings allowed the discussion and review of patients on high risk drugs, prescribing, the risk register and to allow staff to provide feedback.
  • The practice had obtained two paediatric pulse oximeters.
  • There was evidence that support for carers had improved slightly. The practice had identified 37 patients as carers, 1% of the practice list.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(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 improve identification of carers so that they can be offered appropriate support.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

During a routine inspection

This practice is rated as Inadequate overall. (Previous inspection 22 August 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Trinity Medical Centre on 22 August 2017 to follow up on previously identified breaches of regulations. We inspected the practice at 2 Garland Road London SE18 2AE.

The overall rating for the practice following that inspection was Requires Improvement. The full comprehensive report on the 22 August 2017 inspection can be found by selecting the ‘all reports’ link for Trinity Medical Centre on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Trinity Medical Centre on 4 and 10 October 2018 to follow up on breaches of regulation identified in August 2017. We visited on two dates to accommodate the leave of key staff.

At this inspection we found:

  • Systems and processes were in place to keep people safe however some of these systems were not operated effectively to ensure care and treatment to patients was provided in a safe way. For example, patients on high risk medicines were not being monitored properly. After the inspection the practice provided us with evidence of a new system in place to monitor patients.
  • The practice did not always act on appropriate and accurate information.
  • There was an ineffective system for monitoring the prescribing of hypnotics medicines.
  • Since the last inspection the practice had not ensured that the identification of carers had improved.
  • We found there was a lack of systems and processes established that operated effectively to ensure compliance with requirements to demonstrate good governance.
  • The practice now had a system in place to monitor safety alerts.
  • There was a system in place to ensure professional registration and medical insurance of clinical staff was routinely checked on an ongoing basis.
  • The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice did not always learn from them to improve their processes.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use.
  • The practice had undertaken two full cycle audits which demonstrated quality improvement.

The areas where the provider must make improvements are:

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

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Explore ways to improve the uptake of childhood immunisation and cervical screening.
  • Review prescribing of hypnotics.
  • Risk review obtaining a paediatric pulse oximeter.
  • Improve the identification of carers so that they can be offered appropriate support.