Stanley Medical Centre

We carried out an announced comprehensive inspection at Stanley Medical Centre on 17 and 18 April 2023. The practice is rated as requires improvement overall.

Safe - good

Effective - good

Caring - requires improvement.

Responsive - requires improvement.

Well-led - good

At the last inspection, under the previous provider Dr Don Jude Chaminda Mahadanaarachchi, Stanley Medical Centre was rated as inadequate overall, inadequate for being safe and well led, requires improvement for being effective and responsive and good for caring services. The practice was placed into special measures in February 2022.

The new provider of services, a partnership, registered with CQC on 5 December 2022.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Stanley Medical Centre on our website at www.cqc.org.uk

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:

We have rated this practice as requires improvement overall.

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

• The practice had clear systems, practices, and processes to keep people safe and safeguarded from abuse.

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

• Patients’ needs were assessed, and care and treatment were delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.

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

• Feedback from patients in the national GP patient survey were below local and national averages for questions relating to healthcare professionals being good at listening, good at treating with people with care and concern and patients overall experience of their GP practice. The GP partners had not undertaken a practice patient survey to determine if patients’ views had improved.

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

• Robust records were not kept for all complaints received by the practice.
• The national GP survey results indicated that patient views about access issues such as, getting through on the telephone, experience of making an appointment, appointment times and satisfaction with appointment times was below local and national averages. The partners had not undertaken a practice patient survey to determine if patients’ views had improved.

We rated the practice as good for providing well led services because:

• Leaders demonstrated they understood the challenges to quality and sustainability. The practice had a culture that was compassionate, inclusive, and supportive. There were clear and improved processes for managing risks, issues, and performance.

We found one breach of regulations. The provider must:

• Ensure there is an effective system for identifying, receiving, recording, handling, and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

The provider should:

• Take action to ensure all staff at risk of being exposed to blood, body fluids or tissues as part of their work have up to date immunisation vaccination for Hepatitis B Virus.
• Improve staff administration of prescription only medicines under a patient group directive to include appropriate authorisation.
• Continue to take steps to improve the uptake of childhood immunisations and cervical screening rates for people registered at the practice.
• Take action to ensure all patient records are stored safely in line with guidance.
• Take action to ensure robust records are made for all complaints received and this should include all the evidence used to reach the decisions made.
• Increase the frequency for checking the supply of emergency medicines.
• The practice should introduce a patient survey. They should continue to take steps to improve the results of the national GP patient survey.
• Continue to document in the patient record evidence of effective medicines reviews.

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