The Care Quality Commission
  • 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

All Inspections

14, 15 and 16 December 2022

During a routine inspection

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.

22 March 2022

During a routine inspection

We carried out an announced inspection at Gillmoss Medical Centre on 22 March 2022. Overall, the practice is rated as requires improvement.

Safe – requires improvement

Effective – requires improvement

Caring – good

Responsive – requires improvement

Well-led – inadequate

Why we carried out this inspection

This inspection was a comprehensive inspection covering all key questions. The practice was registered with the Commission on 26 March 2021.

How we carried out the inspection/review

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
  • 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
  • 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

The practice is rated as good for caring. Staff treated patients with kindness, respect and compassion.

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

  • The provider could not evidence staff vaccination status.
  • Fire risk assessment and a health and safety risk assessment of the premises had not been completed.
  • We found risks related to the premises the provider had not identified. For example, bolt locks on clinical and toilet doors that could not be accessed externally. The entrance to the practice and some clinical rooms were not suitable for those in a wheelchair or those with a pushchair.
  • The provider’s system to manage significant events was ineffective as not all staff were trained in the process and records of investigations undertaken were not kept.

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

  • The staff induction process was not tailored to specific roles.
  • Staff were not trained to the appropriate level for safeguarding children and not all staff were trained in cardiopulmonary resuscitation and health and safety matters.
  • Appraisals had not been offered to all staff.

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

  • The provider did not keep records of investigations into complaints and a track of actions arising from complaints.
  • Not all staff who dealt with and responded to complaints had received specific training.

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

  • Some members of the leadership team had been recently appointed and their roles and responsibilities had not been clearly set out and were still being developed.
  • Practice staff were not always aware of the roles and responsibilities of members of the leadership team and the lines of accountability within the organisation.
  • The provider’s centralised governance function did not have clear systems and processes in place to support staff at practice level.
  • The provider did not have a documented overall strategy underpinned by detailed, realistic objectives and plans for high-quality and sustainable delivery.
  • The systems for identifying, managing and mitigating some risks were ineffective.
  • There was no leadership development programme in place.
  • The vision, values and strategy were not developed in collaboration with staff, patients and partners.

We found the following breaches of regulations. The provider must:

  • Ensure the 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.
  • Review access for disabled patients and establish effective systems to ensure access is equal for all patients.

The provider should:

  • Continue to work to improve the uptake of screening and immunisation.

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