Trinity Medical Centre

We carried out an announced focused inspection at Trinity Medical Centre on 14 January 2020 because breaches of regulation were found at our previous inspection. We also followed up on concerns received at CQC about how information is managed at the practice.

At the last inspection in November 2018 we rated the practice as requires improvement for providing safe services because:

• A disclosure and barring service (DBS) check or risk assessment had not always been carried out for non-clinical chaperones.
• Actions following an infection control audit had not been completed.
• There was no system to monitor the ongoing registration of nurses.

In November 2018 we also found areas where the provider should make improvements:

• Continue to review the uptake of childhood immunisations with a view to supporting continuing improvements.

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.

Overall the practice continues to be rated as good and is now rated good for providing safe services.

Details of our findings

At this inspection we found:

• The practice had policies and processes in place to make sure disclosure and barring service (DBS) checks were completed for chaperones, and the ongoing registration of nurses was monitored.
• The practice had acted on issues identified from infection control audits and cleanliness checks.
• There were processes to identify, understand, monitor and address current and future risks. The practice was experiencing staffing challenges, but they had safety measures in place to ensure risk was minimised.
• Incoming and outgoing correspondence was processed in a timely manner, by an appropriate staff member, and recorded onto the clinical system.
• Staff were positive about working at the practice and they felt supported by the management team.

The areas where the provider should make improvements are:

• Review and improve the systems to record completed actions as a result of infection control audits.
• Continue to monitor systems and processes to ensure information is processed and recorded in a timely manner.
• Continue to review and take action to improve child immunisation uptake rates.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive/focused inspection at Trinity Medical Centre on 23 November 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice had systems in place to manage the control of infection, however, action from the annual risk assessment had not always been completed.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had reviewed and improved appointment access in response to patient feedback. Patients reported improvements in accessing care when they needed it and found the appointment system easy to use.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice did not achieve the target for the uptake of childhood immunisations, however they had taken some action to improve this and this had been reflected in the improved results seen during the inspection.
• Patients were positive about their experience within the practice and staff reported feeling well supported by management and a positive team approach.
• Recruitment processes were in place, however disclosure and barring service checks for non-clinical chaperones were not always carried out and there was no record of ongoing registration checks for nursing staff.
• The practice identified carers and provided support and access to other services for them.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure, where appropriate, persons employed are registered with the relevant professional body.

The areas where the provider should make improvements are:

• Continue to review the uptake of childhood immunisations with a view to supporting continuing improvements.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.