The Mayfair Medical Centre

We carried out an announced comprehensive inspection at The Mayfair Medical Centre on 18 and 27 January 2023. Overall, the practice is rated as Requires Improvement.

The key questions are rated as:

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

Why we carried out this inspection

This was a comprehensive inspection. This was a new registration and we carried out this inspection as part of our regulatory functions.

At this inspection we covered all key questions:

• Are services safe?
• Are services effective?
• Are services caring?
• Are services responsive?
• Are services well-led?

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.
• 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 found that:

• There was a lack of good governance in some areas.
• Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations and records were not kept in staff files.
• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms and pads were recorded correctly, and their use was monitored in line with national guidance.
• Our clinical records searches showed that the practice did not always have effective systems in place to ensure the monitoring of some high risk medicines and patients with long term conditions.
• Risks to patients were not assessed and well managed in relation to some safety alerts, Patient Specific Directions (PSDs) and the management of legionella.
• The Patient Participation Group (PPG) was not active.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• Feedback from patients was positive about the way staff treated people.
• The practice carried out repeated clinical audits.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We found three breaches of regulations. The provider must:

• 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.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

• Continue to encourage the patient for cervical, breast and bowel cancer screening and childhood immunisation uptake.
• Establish the Patient Participation Group (PPG).

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