Hall Street Medical Centre

We carried out an announced comprehensive inspection at Hall Street Medical Centre on 11 October 2023. Overall, the practice is rated as good.

The key question ratings are as follows:

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led – Good

This is the first inspection of Hall Street Medical Centre since it was registered under a new provider with CQC in July 2022 .

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. We inspected all of the key questions as part of this 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.
• Requesting evidence from the provider.
• A 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:

We rated the provider as good for providing safe services. This was because:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Staff had the information they needed to deliver safe care and treatment.

We rated the provider as requires improvement for providing effective services. This was because:

• Patients with long-term conditions were not always receiving appropriate monitoring or reviews.
• Do not attempt cardio pulmonary resuscitation records (DNACPR) were either incomplete or could not be located.
• The practice was not meeting the target for cervical screening uptake for eligible patients.

We rated the provider as good for providing caring services. This was because:

• Staff treated patients with patients with kindness and respect.
• The practice respected patient’s privacy and dignity.

We rated the provider as good for providing responsive services. This was because:

• The practice organised and delivered services to meet patient’s needs.
• Patients could access care and treatment in a timely way.

We rated the provider as good for providing well-led services. This was because:

• There was compassionate and inclusive leadership at all levels.
• There was evidence of systems and processes for learning, continuous improvement and innovation.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Update training records to ensure gaps in training for staff such as infection, prevention and control are addressed.
• Improve the appraisal schedule to clarify the appraisers and appraisal dates for staff employed by the PCN in advanced clinical practice.
• Progress plans to improve the cervical screening uptake for eligible patients.

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