Scott Arms Medical Centre

We carried out an announced comprehensive at Scott Arms Medical Centre on 27 September 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - requires improvement

Responsive – inadequate

Well-led - requires improvement

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was a new registration and the practice had not been inspected previously under this provider.

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 clinical 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:

• Patients’ needs were assessed; however, care and treatment was not always delivered in line with current standards and evidence-based guidance.
• Governance systems required strengthening to ensure risks were mitigated. For example, we identified concerns in relation to the actioning of safety alerts and monitoring and follow-up of patients with long-term conditions.
• The provider could not demonstrate there was an effective process in place to ensure vaccine fridges were monitored appropriately and relevant action taken where needed.
• The provider was acting to improve appointment and telephone access, however, patient feedback through the National Patient Survey had decreased significantly over the past 2 years in relation to access and the provision of care.
• The practice learned from incidents, events and complaints and ensured learning was shared amongst the staff team.
• We found the premises were well maintained, appeared clean and tidy and had appropriate infection prevention and control arrangements in place.

We found 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.

The provider should:

• Improve uptake of cervical cancer screening and children’s immunisations to meet minimum targets.

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 Health Care