• Doctor
  • GP practice

St Martins Medical Centre

Overall: Good read more about inspection ratings

21 Eastcote Road, Ruislip, Middlesex, HA4 8BE (01895) 632410

Provided and run by:
St Martins Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about St Martins Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about St Martins Medical Centre, you can give feedback on this service.

21 February 2020

During an annual regulatory review

We reviewed the information available to us about St Martins Medical Centre on 21 February 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

27 November 2018

During a routine inspection

We carried out an announced comprehensive inspection at St Martins Medical Centre on 27 November 2018 as part of our inspection programme.

At the last inspection in October 2017 we rated the practice as requires improvement for providing safe and well-led services because:

  • The processes for monitoring patients taking warfarin was inconsistent.
  • There were deficiencies in managing prescription security and uncollected prescriptions.
  • Records for monitoring fridge temperatures and decontaminating medical equipment were not consistently maintained.
  • There were premises related concerns contributing to poor maintenance and infection control processes.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service is 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 and good for all population groups, except the long-term conditions group which was rated as requires improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs. Although, some outcomes for patients with diabetes and asthma were below local and national averages.
  • 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Take interim action to identify and minimise the risks associated with fire at the main practice.
  • Continue to review and improve patient satisfaction with waiting times and access to appointments.

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

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

24 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Martins Medical Centre on 23 February 2016. The practice was rated as requires improvement for providing safe, effective, and well-led services, and good for providing caring and responsive services. Overall the practice was rated as requires improvement. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for St Martins Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive follow up inspection on 24 October 2017 to check for improvements since our previous inspection. The practice is now rated as requires improvement for safe and well-led services, and good for providing effective, caring, and responsive services. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Risks to patients were assessed but were not well managed. The practice needed to improve the processes for monitoring patients taking warfarin; uncollected repeat prescriptions; responding to emergencies; infection prevention and control; and monitoring fridge temperatures.
  • The practice was equipped to treat patients and meet their needs. However, there were premises-related concerns contributing to poor maintenance of the building that required improvement.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Clinical audits demonstrated quality improvement.
  • Results from the national GP patient survey (July 2017) showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Some feedback from patients we spoke with and Care Quality Commission comment cards highlighted difficulties with making an appointment. Urgent appointments were available the same day.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

  • Maintain appropriate standards of hygiene for premises and equipment.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

  • Review the systems for: checking uncollected blank prescriptions; recording and acting on safety alerts; and the storage of blank prescriptions in consulting rooms.
  • Review ways to improve patient satisfaction with making an appointment and the punctuality of appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Martins Medical Centre on 23 February 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews were not thorough enough to prevent a reoccurrence and there was no guidance on what constituted significant events for staff to refer to.

  • Some risks to patients had been assessed, however improvements were required to risks relating to recruitment, training, health and safety, fire safety, and infection control.

  • Data showed patient outcomes were in line with local and national averages. However, we saw no evidence that clinical audits were driving improvement in performance to improve patient outcomes.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

  • Information about how to complain was available, although it was not easily accessible to patients.

  • Urgent appointments were usually available on the day they were requested, and patients could access a male and female GP.

  • The practice had some policies and procedures to govern activity, but some were missing or were overdue a review.

  • There was a new leadership structure however some staff were not sure of the roles of other staff and did not feel supported by management or involved in how to improve the practice.

  • The practice had sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

  • Ensure risk assessments related to fire safety, the testing of electrical equipment, and infection control are carried out, and action is taken to ensure patients are kept safe.

  • Carry out clinical audits and re-audits to inform and improve patient outcomes.

  • Ensure staff are supported with professional development and supervision, and receive training to enable them to undertake their role.

  • Ensure staff who act as chaperones have received the necessary pre-employment checks and assess their competency to carry out this role.

  • Ensure staff receive appraisals so their developments needs are identified and acted on.

  • Ensure policies and protocols are in place and up to date to assist staff with significant event reporting, infection control, the secure storage and monitoring of prescriptions, repeat prescribing, health and safety, and referrals.

In addition the provider should:

  • Ensure information is available for locum staff.
  • Address the actions identified in the external clinical risk assessment.
  • Review patient feedback, particularly from the national GP patient survey.
  • Ensure the practice actively identifies patients who are also carers.
  • Ensure patients have easy access to the complaints system and online facilities to book appointments and order repeat prescriptions.
  • Ensure translation services are available to patients on request.
  • Ensure staff are aware of the vision and strategy for the practice and involve them in making improvements on how the practice is run.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 January 2014

During a routine inspection

During our inspection we spoke with five people using the service, the practice manager, deputy practice manager, practice nurse and two GP's. We viewed two patient records. People told us they were happy with the service that they received and that staff were overall friendly, polite and professional. Comments included 'It's quiet easy to get an appointment, I got an emergency appointment today', and 'my doctor is very thorough, they always give me options and if there is any concern about any test results they call me'.

People told us they were offered explanations regarding medical conditions and the treatment options that were available.

Systems were in place for safeguarding children and adults.

There were enough qualified, skilled and experienced staff to meet people's needs. Staff were appropriately supported to ensure they were sufficiently skilled to care and support people who use the service.

The provider had in place an effective complaints management system. People we spoke with told us they were confident that they could raise any concerns they had.