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The Stanmore Medical Centre Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 24 June 2019

We carried out an announced comprehensive inspection at The Stanmore Medical Centre on 25 April 2019 as part of our inspection programme.

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 requires improvement overall and for all population groups.

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

  • The practice did not have clear systems and processes to keep patients safe. This included recruitment checks, staff immunisations, equipment checks, fire and health and safety, infection control and mandatory staff training.
  • The processes in place to protect patients from avoidable harm required improvement. This was in relation to the timely review of pathology results, significant events and near misses.
  • Not all staff had received training on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.
  • The practice did not have appropriate systems in place for the safe management of medical gases, medicines and prescriptions.

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

  • The practice was unable to demonstrate what action had been taken to improve patient experience in relation to listening to patients and treating them with care and concern.
  • Privacy screens were not provided in all clinical rooms.

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

  • Patients did not always receive timely access to the practice.
  • There was limited evidence to show what learning took as a result of complaints.

We rated the practice as requires improvement for providing well-led services because:

  • Leaders could not always demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
  • While the practice had a clear vision, that vision was not supported by a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • The systems for continuous learning and improvement were not always implemented effectively.

These areas affected all population groups so we rated all population groups as requires improvement

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

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

  • The practice had taken steps to improve their cervical cancer screening uptake.
  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles, although some monitoring was required.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure recruitment procedures are established and operated effectively.

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

The areas where the provider should make improvements are:

  • Improve the display of chaperone notices around the practice.
  • Continue to monitor and improve the cervical screening uptake rates.
  • Take action to install a hearing loop.

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

Inspection areas


Requires improvement




Requires improvement


Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement