8 and 9 December 2022
During a routine inspection
We carried out an announced comprehensive inspection at Mayflower Medical Group on 8 and 9 December 2022.
Overall, the practice is rated as Good
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Mayflower Medical Group was taken over on 1 April 2022 by a new provider called “Livewell Primary Care Group Limited”. Livewell Primary Care Group Limited are registered with the Care Quality Commission (CQC). This is the first inspection since the new provider (Livewell Primary Care Group Limited) registered with CQC.
We previously inspected the location under a different provider. Details of this inspection and the reports from inspections under the previous provider can be found by selecting the ‘all reports’ link for Mayflower Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection.
We carried out this inspection in line with our inspection priorities as it was Mayflower Medical Groups first inspection since the new provider Livewell registered with CQC.
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 two day site visit.
- A pre-site visit staff questionnaire
We carried out an announced comprehensive inspection at Mayflower Medical Group on 8 and 9 December 2022.
Overall, the practice is rated as Good
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Mayflower Medical Group was taken over on 1 April 2022 by a new provider called “Livewell Primary Care Group Limited”. Livewell Primary Care Group Limited are registered with the Care Quality Commission (CQC). This is the first inspection since the new provider (Livewell Primary Care Group Limited) registered with CQC.
We previously inspected the location under a different provider. Details of this inspection and the reports from inspections under the previous provider can be found by selecting the ‘all reports’ link for Mayflower Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection.
We carried out this inspection in line with our inspection priorities as it was Mayflower Medical Groups first inspection since the new provider Livewell registered with CQC.
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 two day site visit.
- A pre-site visit staff questionnaire
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 an open and transparent approach to patient safety and an effective new system for reporting and recording significant events, incidents and complaints.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- 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.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- There was a clear leadership and governance structure and staff felt supported by management.
- There was a dedicated quality improvement lead and a lead for managing safety alerts.
- There was a clear embedded process for the distribution and action of safety alerts.
- Published results showed the childhood immunisation uptake rates were above the 90% minimum target.
We found the following areas of outstanding practice:
- The new provider had installed a new computer system for the recording of significant events, incidents, complaints and compliments which was called “InPhase”. The system was able to link trends and themes to identify similar issues which enabled the practice to make improvements where required. Learning is based on a thorough analysis and investigation of things that go wrong. All staff are encouraged to participate in learning to improve safety as much as possible, including working with others in the system and where relevant participating in local and national safety programmes. External agencies recognise the practice’s innovative use of technology and are looking to integrate this model across Devon.
- All staff are open and transparent, and fully committed to reporting incidents and near misses. The level of quality of incident reporting shows the levels of harm and near misses, which ensures a robust picture. Every incident that is reported is individually reviewed or investigated and actions taken. The practice had introduced a panel who met monthly to review specific learning from the patient safety events (LFPSE). The panel is made up of senior clinicians and identifies learning and improvement from events that have a harm rating of moderate or above or have been reported as a Notifiable Safety Incident. Low or no harm events are categorised according to themes. The LFPSE panel determine the action plans, and feed down to the clinical meetings and report back to LPSE panel when actions are completed.
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