We carried out a review of the data available to us about St Ann's Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Ann's Medical Centre, you can give feedback on this service.
We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as good overall and for all population groups apart from working age people which is rated as requires improvement.
We rated the practice as requires improvement for working age people becau se:
Whilst we found no breaches of regulations, the provider should :
We saw two areas of outstanding practice:
Following management changes, a whole practice review was undertaken. Areas for improvement were implemented as part of the practice improvement programme. As part of this the practice identified further engagement with patients was required. A Patient Engagement Officer role was introduced and tasked with coordinating patient feedback. As a result of feedback from patients, a six-month probation period was introduced to support and mentor new staff. Staff told us they found this approach welcoming and supportive.
The practice review also identified a high level of complaints from patients which were not themed into categories. This was undertaken and as a result, further customer care training was delivered to staff, and care navigation implemented. A telephone call auditing tool was introduced in 2018 to measure the effectiveness and quality of the calls answered at the practice. The results from 2018 demonstrated that 79% of calls audited met the required competencies, whereas the most recent audit in March 2020 demonstrated all the competencies were met. In addition, the number of complaints to the practice had significantly reduced from 24 in 2018 to eight in 2019.
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
We carried out an announced comprehensive inspection at St Ann’s Medical Centre on 15 and 16 October 2015 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The overall rating for the practice was good but with requires improvement for safe. We carried out a focused follow up inspection on 21 and 24 June 2016 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. We found there had been some improvements at this inspection. The overall rating for the practice was good with good for safe but with requires improvement for well led as there were areas for improvement relating to governance.
We carried out a focused announced inspection on 27 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 and 24 June 2016. We found there had been some improvement in governance arrangements although these had not always been effectively implemented and the practice continued to require improvement in well led.
The reports for these inspections can be found by selecting the ‘all reports’ link for St Ann’s Medical Centre on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 12 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in April 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated as Good.
Improvements to meet regulations had been made since our last inspection in April 2017. Our key findings were as follows:
There had been improvement in governance arrangements to ensure vaccines were stored safely.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Ann’s Medical Centre on 15 and 16 October 2015. The overall rating for the practice was good but with requires improvement for safety. We carried out a focused follow up inspection on 21 and 24 June 2016 to check that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 and 16 October 2015. We found there had been some improvements at this inspection and the practice was rated as good for safety. The overall rating for the practice was good but with requires improvement for well led following this inspection as we found some areas for improvement relating to governance. The reports for both these inspections can be found by selecting the ‘all reports’ link for St Ann’s Medical Centre on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 27 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 and 24 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated as Good.
Improvements to meet regulations had been made since our last inspection on 21 and 24 June 2016. Our key findings were as follows:
There had been some improvement in governance arrangements and staff responsibilities had been clarified to ensure governance systems were implemented. For example, the recruitment procedure and infection control action plan had been implemented and monitored.
Procedures to monitor vaccine fridge temperatures had been applied more consistently although these had not been effective in ensuring the correct temperatures were maintained.
Systems to ensure patient records were stored securely had been improved.
In addition the provider had:
Implemented systems to improve the availability of non-urgent appointments.
Improved complaints investigation records.
The practice must improve the following areas:
The provider must improve cold chain monitoring arrangements to ensure correct temperatures for vaccine storage are maintained. The provider must ensure all those involved in administering vaccines and monitoring the temperatures of vaccine storage understand what to do in the event of a failure in the cold chain.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection of this practice on15 and 16 October 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulation 12, safe care and treatment, and Regulation 19, fit and proper persons employed.
We undertook this focused inspection on 21 and 24 June 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for on our website, St Ann's Medical Centre, at www.cqc.org.uk. Overall the practice is rated as requires improvement.
Specifically, following the focused inspection we found the practice to be requires improvement for providing safe, responsive and well-led services.
Our key findings across all the areas we inspected were as follows:
The provider had implemented a number of improvements recommended at the last inspection for example they had;
Implemented systems to identify risks relating to infection prevention and control and to monitor and maintain standards. Maintained systems to minimise the risk of cross contamination in relation to hand washing at the branch surgery.
Improved recruitment procedures although the recruitment procedure was not fully implemented.
Implemented systems for formal analysis of significant events to enable the practice to identify patterns and trends over time.
Clarified who was responsible for managing medical alerts and implemented systems to ensure these had been actioned.
Improved arrangements for the storage of oxygen and ensured appropriate and consistent signage was implemented for oxygen storage areas.
Importantly, the provider must:
Improve governance arrangements and clarify staff responsibilities to ensure governance systems are fully implemented. For example, the recruitment procedure, infection control action plan and procedures to monitor vaccine fridge temperatures at the branch surgery must be fully implemented and monitored.
Patient records must be stored securely.
In addition the provider should:
Improve the availability of non-urgent appointments.
Maintain records of complaints investigations.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Anne’s Medical Centre on 15 and 16 October 2015. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
We saw one area of outstanding practice:
However there were areas of practice where the provider needs to make improvements.
Importantly, the provider must:
In addition the provider should:
Chief Inspector of General Practice