The Care Quality Commission
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Mallard Medical Practice

Overall: Requires improvement read more about inspection ratings

Killingworth Health Centre, Citadel East, Killingworth, Newcastle Upon Tyne, Tyne And Wear, NE12 6HS (0191) 216 0061

Provided and run by:
Mallard Medical Practice

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of Assessment: 7 February 2025 to 16 February 2025. Mallard Medical Practice is a GP practice and delivers service to 5,447 under a contract held with NHS England. The National General Practice Profiles states that the patient population is predominately white (96.13%) with a small mix of other ethnicities. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7th decile (7 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report. There was a risk that patients were not protected from abuse and avoidable harm because the service did not always have a proactive and positive culture of safety based on openness and honesty. However, we found the service made sure that medicines were managed appropriately. Staff reviewed people’s care and worked with other services to achieve this. However, there were some gaps in the way the practice recalled patients for regular reviews. The service made sure that people could access the care, support, and treatment they needed when they needed it. Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. There was a lack of effective leadership, cohesive vision, and strategy within the practice. Governance processes were ineffective, which meant leaders did not always act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

We found breaches of regulation in relation to staffing, recruitment and good governance. We have asked the provider for an action plan in response to the concerns found.

06/08/2020 to 12/08/2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Mallard Medical Practice on 8 November 2019. The overall rating for the practice was good, but it was rated as requires improvement for the safe domain. The full comprehensive report on the November 2019 inspection can be found by selecting the ‘all reports’ link for Mallard Medical practice on our website at .

This inspection was a desk-based review carried out on 6th to 12th August 2020 to confirm that the practice had made the improvements. This report covers our findings in relation to those requirements.

The practice remains rated as Good overall and has improved its rating of Requires Improvement for the safe domain to Good.

Our key findings were as follows:

At the inspection in November 2019 we rated the practice as requires improvement for providing safe services because:

  • We were not assured that patients had been individually assessed to ensure it was medically appropriate for them to receive vaccines under a Patient Specific Direction (PSD).

  • There was no system in place to ensure that patient safety alerts had been read and actioned.

  • Systems which kept patients safe required improvement, such as the system for checking emergency medicines.

At this review we found that the practice had made the necessary improvements as follows:

  • We were supplied with evidence of a template now used by the practice on individual patients to assess and authorise whether the medicine was safe to administer by Patient Specific Direction.
  • Safety alerts were now received by both Co-Practice Managers, to ensure action of the safety alerts if one of the members of staff are absent. They were added to a web-based sharing & compliance platform designed for primary care.
  • At the inspection in November 2019 we saw that the system in place to monitor stock levels of emergency medicines was not consistent as there were three checklists. We also saw that there were medicines in stock that were not on a checklist. At this focused inspection we were shown evidence of a much clearer system. The practice now used one checklist with all emergency medicines stocked on this list.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

8 Nov 2019

During a routine inspection

We carried out an announced comprehensive inspection at Mallard Medical Practice on 8 November 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 7 November 2018 (last inspection rating: requires improvement).

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 have rated this practice as good overall.

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

  • We were not assured that patients had been individually assessed to ensure it was medically appropriate for them to receive vaccines under a Patient Specific Direction (PSD).
  • There was no system in place to ensure that patient safety alerts had been read an actioned.
  • Systems which kept patients safe required improvement, such as the system for checking emergency medicines.

We rated the practice as good for providing effective, caring, responsive and well led services because:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The practice had a culture which drove high quality sustainable care.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Make changes to the system for disseminating safety alerts so that it is clear alerts have been read and actioned;
  • Continue to ensure that all systems which have been put in place are clearly communicated to staff and are checked to ensure they are being followed correctly;
  • Continue to work towards ensuring 80% of women eligible for cervical cancer screening at a given point in time are screened adequately.

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

7 November 2018

During a routine inspection

This practice is rated as requires improvement overall (previous rating under former provider December 2015 – good).

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? – Requires improvement

Are services well-led? – Requires improvement

We carried out an announced inspection at Mallard Medical Practice on 7 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had some systems in place to manage risk. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care they provided. They ensured that care and treatment was delivered according to evidence- based guidelines.
  • There was a focus on continuous learning and improvement; although learning was not always shared across the whole practice team.
  • The practice had effective arrangements in place to monitor prescribing and usage of hypnotic type medicines (to aid sleeping); prescribing rates were much lower than local and national averages.
  • The practice’s medicines management arrangements were effective but vaccines and blank prescriptions were not always stored securely.
  • Some staff had not received appropriate training.
  • Patients had not always been advised of cancelled appointments.
  • Arrangements for the confidentiality of records and data management systems were not always robust.

The areas where the provider must make improvements are:

  • 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 areas where the provider should make improvements are:

  • Develop a system to provide assurance that clinical staff employed by the practice remain registered with their professional body.
  • Review the practice’s appointments system; continue to look for ways to improve how patients can access services and prevent errors when appointments are cancelled.
  • Take steps to ensure staff undertake fire safety and children’s safeguarding training.

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.