• Doctor
  • GP practice

Gillmoss Medical Centre

Overall: Requires improvement read more about inspection ratings

48 Petherick Road, Liverpool, Merseyside, L11 0AG

Provided and run by:
Dr Don Jude Mahadanaarachchi

Important: The provider of this service changed. See old profile

Latest inspection summary

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Background to this inspection

Updated 17 February 2023

Gillmoss Medical Centre is located in the Croxteth area of Liverpool at:

48 Petherick Road

Liverpool

Merseyside

L11 0AG

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.

The provider has other separate provider registrations and locations registered with the Commission.

The practice is situated within the Cheshire and Merseyside Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 2320. This is part of a contract held with NHS England. The practice is part of a wider network of GP practices.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the lowest decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. A lower level of deprivation can indicate challenges in providing healthcare. The supply of healthcare services tends to be lower in more deprived areas due to a number of factors but has an increased demand. The population tends to have poorer health status among individuals with a greater need for health services. For example, there may be higher levels of long-term conditions such as those affecting the cardiovascular system and respiratory system. This practice has a higher than local and national average prevalence of asthma, chronic obstructive pulmonary disease, obesity, hypertension, depression and diabetes.

According to the latest available data, the ethnic make-up of the practice area is 94.9% White, 2.1% Asian, 1.6% Black, 1.1% Mixed and 0.3% Other.

There are a higher number of older people registered at the practice compared to the national average and a lower number of young people registered.

There is a team of GPs, advanced nurse practitioners, practice nurses, clinical pharmacists and a pharmacy technician. The clinical team are supported by a team of reception/administration staff. The practice manager provides managerial oversight supported by a central governance team.

The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by another of the provider’s registered practices, where late evening and weekend appointments are available. Out of hours services are provided by PC24.

Overall inspection

Requires improvement

Updated 17 February 2023

We carried out an announced comprehensive inspection at Gillmoss Medical Centre on 14, 15 and 16 December 2022. 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 22 March 2022 the practice was rated requires improvement overall and for the key questions safe, effective and responsive. Caring was rated as good and well-led was inadequate.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • A short 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 requires improvement overall.

We rated the practice as requires improvement for providing safe services. This is because:

  • Not all patients prescribed high risk medicines had the appropriate monitoring in place.
  • Recruitment checks were not always carried out according to Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • There were gaps in systems to monitor and assess risks related to the health and safety of patients, staff and visitors.
  • The provider did not keep cleaning records for the premises.
  • Although the provider had a process in place to manage significant events, records of investigations were not kept and not all staff who responded to these were trained in the process.

We rated the practice as requires improvement for providing effective services. This is because:

  • The practice achievement in cervical cancer screening was below nationally set targets.
  • People with long term conditions were not always reviewed in line with national guidance which required regular monitoring of their condition to prevent further harm.

We rated the practice as good for providing caring services. This is because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as good for providing responsive services. This is because:

  • Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing well-led services. This is because:

  • Although the practice had made changes to the management of the practice these had not had time to demonstrate effectiveness.
  • The systems for identifying, managing and mitigating some risks were not always effective.

We found one breach of regulations. The provider must:

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

The provider should:

  • Ensure works are undertaken to make the premises more accessible for disabled people.
  • Carry out checks of emergency medicines weekly.
  • Continue to undertake medication reviews for patients prescribed repeat medicines.
  • Ensure medicines safety alerts are acted on without delay.
  • Continue to work to improve the uptake of cervical cancer screening and immunisation.
  • Implement a detailed strategy to support high quality and sustainable care.

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.