We previously carried out an announced comprehensive inspection at The Stanmore Medical Centre on 25 April 2019. The overall rating for the practice was requires improvement, with the exception of key question Effective which was rated good. The full report on the 25 April 2019 inspection can be found by selecting the ‘all reports’ link for The Stanmore Medical Centre on our website at www.cqc.org.uk.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring – Good
Responsive – Requires improvement
Well-led - Good
This inspection was an announced comprehensive follow-up inspection carried out on 3 August 2021 to confirm that the practice continued to make improvements on areas that we had identified at our previous inspection held on 25 April 2019. This report covers our findings in relation to those improvements and also additional improvements made since our last inspection. This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to review progress against previous breaches of regulation
- 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.
- 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.
- Patients did not always receive timely access to the practice.
- There was limited evidence to show what learning took as a result of complaints.
- Leaders could not always demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
- The overall governance arrangements were ineffective.
- The systems for continuous learning and improvement were not always implemented effectively.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
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.
At this inspection we found there had been sufficient improvement to rate the safe, effective, caring and well-led key questions good, however responsive would remain as requires improvement as the practice had not improved patient experience in relation to accessing appointments and services. The ratings for the practice is now good overall.
We found that:
- The practice had developed 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.
- There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
- All staff had received training on identifying deteriorating or acutely unwell patients and had had Sepsis training, there were posters in reception and clinical rooms.
- The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
- The practice was able to demonstrate what action had been taken to improve patient experience in relation to listening to patients and treating them with care and concern.
- Patient survey results however were still lower than local and national averages for access to services..
- Privacy screens were available in all clinical rooms.
- Due to patient feedback the service had installed a new telephone system, increased the amount of administration and reception staff and introduced an online triage system to augment the existing telephone triage.
- Leaders could demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
- The practice had a clear vision, that vision was supported by a credible strategy. The service had made several improvements to improve patient care in the last 12 months.
- The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
- The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, we reviewed the recruitment and training files for five members of staff and found that all of the recommended checks and training had been completed.
- All staff received up-to-date safeguarding and safety training appropriate to their role.
- The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients.
Whilst we found no breaches of regulations, the provider should:
- Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
- Continue to improve and review the management of complaints.
- Continue to review the National GP Patient Survey results and make improvements with patient satisfaction with accessing services.
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