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  • GP practice

Archived: Mayflower Medical Group - Stirling Road Surgery

Overall: Inadequate

Stirling Road, Plymouth, Devon, PL5 1PL (01752) 982200

Provided and run by:
Access Health Care Ltd

The provider of this service changed. See new profile
The provider of this service changed. See old profile

Latest inspection summary

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Background to this inspection

Updated 4 February 2022

Mayflower Medical Group is located in Pymouth at:

Mayflower Medical Group- Stirling Road

Stirling Road



The practice has 5 branch surgeries at:

Ernesettle Medical Centre

Ernesettle Green



Mount Gould Medical Centre

200 Mount Gould Road



Trelawny GP Surgery

45 Ham Drive



Mannamead Surgery

22 Eggbuckland Road


Plymouth, PL3 5HE

Collings Park Surgery (currently closed)

57 Eggbuckland Road




The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures. These are delivered from all five sites.

The practice offers services from the main practice and the branch surgeries. Patients can access services at all surgeries.

The practice is situated within the Devon Clinical Commissioning Group (CCG) and delivers Alternative Provider Medical Services (APMS) service to a patient population of about 37,340. Mayflower Medical Group has evolved over the past four years as Independent Practitioner Practices and other organisations resigned their contracts to provide GMS/PMS services. Access Health Care Ltd was commissioned to run the practices and prepare for a procurement process that is now due to occur in April 2022. The Practice is exclusively a salaried service, Access Health Care Ltd being a subsidiary of Devon Doctors a Community Interest Company. Mayflower Medical Group use the Devon Doctors shared services for HR, finance and some governance processes.

Information published by Public Health England report deprivation within the practice population group as two on a scale of 1 to 10. Level one represents the highest levels of deprivation and level 10 the lowest. The age distribution of the practice population closely mirrors the local and national averages.

There is a team of salaried GPs two of which are clinical leads and a team of remote GPs. The practice team also consisted of advanced nurse practitioners, practice nurses, healthcare assistants and paramedics. They were supported by a management team, administrators and call handlers.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most appointments, following an eConsult were telephone consultations. If the patient was in need of a face-to-face appointment then the patient is offered a choice of either the main GP location or one of the branch surgeries.

Out of hours services are provided by Devon Doctors.

Overall inspection


Updated 4 February 2022

We carried out a desk based review of Mayflower Medical Group on 21 September 2021. The ratings have not changed because we did not visit the practice.

Safe - Inadequate

Effective - Inadequate

Caring – Requires Improvement

Responsive - Inadequate

Well-led - Inadequate

Following our previous inspection on 26 May 2021 the practice was rated Inadequate overall and for all key questions except caring which was rated as requires improvement.

We issued the provider with requirement notices for breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, related to staffing in regards to training, professional development, supervision and appraisal of staff.

We also issued the provider with warning notices for breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, related to safe care and treatment and good governance.

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

Why we carried out this review

We have continued to monitor the provider’s progress against their action plan which included regular meetings with the provider and Devon Clinical Commissioning Group.

To gain further assurances we undertook a remote regulatory assessment on 21 September 2021. During the assessment we reviewed Mayflower Medical Group – Stirling Road Surgery clinical records system which included the practice’s management system and a sample of patient’s electronic records.

Our findings

We found that:

  • The practice did not have clear systems and processes to keep patients safe.

  • The practice did not have appropriate systems in place for the safe management of medicines.

  • There was not a process in place for monitoring patients’ health in relation to the use of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing.

  • The practice did not manage safety alerts effectively or provide evidence that patient medical alerts were actioned and managed appropriately.

  • Effective systems and processes to ensure good governance were not in place.

Following this inspection and due to the seriousness of the continuing concerns found, the CQC, served a Letter of Intent under Section 31 of the Health and Social Care Act 2008. This was because the Commission had reasonable cause to believe that unless it acts under this section any person will or may be exposed to the risk of harm. This letter offered the registered provider the opportunity to put forward documentary evidence which may provide assurance that the risks identified had already been removed or were immediately being removed.

Following on from the desk top review and the Letter of Intent, subsequently issued, the practice submitted to us an action plan outlining how they would make the necessary improvements to comply with our findings.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients with an effective programme of monitoring and support to meet their needs.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care