Background to this inspection
Updated
26 May 2021
Mendlesham Medical Group is located at The Health Centre, Chapel Road, Mendlesham, Stowmarket, Suffolk, IP14 5SQ. The practice area covers the village of Mendlesham and the outlying villages. The practice is open weekdays from 8am to 6.30pm. There is a branch site, Bacton Surgery, Church Road, Bacton, Stowmarket, IP14 4LJ. This site is open Monday, Tuesday and Thursday from 8am to 6pm and on Wednesday and Friday from 8am to 12.30pm. There is a dispensary at both sites.
We visited Mendlesham Medical Group as part of this inspection.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures.
The practice is situated within the Ipswich and East Suffolk Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 7600. This is part of a contract held with NHS England. The practice is part of a primary care network (PCN) of 16 GP practices called East Suffolk PCN. The practice is also part of the integrated neighbourhood team which includes five practices from the PCN.
Information published by Public Health England report deprivation within the practice population group as 7 on a scale of 1 to 10. Level one represents the highest levels of deprivation and level 10 the lowest. People living in more deprived areas tend to have greater need for health services.
The National General Practice Profile describes the practice ethnicity as being 98.8% white British. Practice demographics show a slightly higher than average percentage of people in the 75+ year age group. Average life expectancy is 83 years for men and 85 years for women compared to the national average of 79 and 83 years respectively. The general practice profile shows that 0.7% of patients registered at the practice were unemployed, compared to 1.9% locally and 4.2% nationally.
The practice team comprises three GP partners (two female and one male) and two salaried GPs (one female and one male). There are two nurse practitioners, two practice nurses and two healthcare assistants. There is a practice manager, assistant practice manager and operations manager and a team of 11 administrative, secretarial and reception staff. The dispensary team is led by a dispensary manager and includes nine trained and dedicated dispensary staff members.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient was seen at Mendlesham Medical Group or at home if necessary.
Patients could book evening and weekend appointments with a GP through Suffolk GP+ (Suffolk GP+ is for patients who urgently need a doctor’s appointment or are not able to attend their usual GP practice on a weekday.) Out-of-hours GP services are provided by Suffolk GP Federation C.I.C., via the NHS111 service.
The practice is a training practice for medical students for the clinical school of Cambridge University. Due to COVID-19 the practice did not have any students at the practice at the time of the inspection but planned to start supporting students in Autumn 2021.
Updated
26 May 2021
We carried out an announced inspection at Mendlesham Medical Group on 4 May 2021. Overall, the practice is rated as good. The ratings for each key question are:
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led – Good
Following our previous report published April 2020 the practice was rated requires improvement overall and for providing safe and well led services. Effective services were inspected and rated good. The ratings for caring and responsive services were carried forward from the previous inspection and were rated good. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Mendlesham Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection
Following our review of the information available to us, including information provided by the practice, we completed a comprehensive inspection. This was because there may have been a significant change to the quality of care provided since the last inspection. This inspection included a site visit to:
- Inspect the key questions of safe, effective, caring, responsive and well led.
- To follow up on breaches of regulation 12 and 17 and areas where the provider ‘should’ improve identified in our previous inspection
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.
This included:
- 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
- Conducting staff interviews using video conferencing and by telephone
- Staff questionnaires
- Requesting evidence from the provider and reviewing this
- Requesting feedback from other stakeholders and patients who use the service
- A short site visit
Our findings
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 and good for providing safe, effective, caring, responsive and well led services. All the population groups were rated as good except for people whose circumstances make them vulnerable, which we rated outstanding for responsive services. Due to our rating aggregation principles the population group people whose circumstances make them vulnerable is rated outstanding.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. Improvements had been made to the oversight arrangements for infection control and fire safety. Annual professional registration checks were completed and documented.
- Improvements had been made to the oversight of the dispensary. Standard Operational Procedures (SOPs) had been written and updated for areas of practice identified at our previous inspection. These were mostly written in March 2021 and signed up to by all dispensary staff a few days before the inspection site visit. However, we saw evidence from practice documentation that correct processes had been followed prior to this.
- Patients received effective care and treatment that met their needs. The practice were working to strengthen their monitoring arrangements for patients prescribed specific medicines.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- There was a proactive approach to service delivery and partnership working with patients with a learning disability and their carers, to ensure their health needs were prioritised and met.
- Due to COVID-19, the practice had appointed a domestic abuse advocate at the practice. They had completed additional training and had shared resources for support with all practice staff.
- The practice had a written strategy and business plan which prioritised quality and sustainability. Systems and processes for governance had been strengthened and embedded and the registration of the provider was accurate and up to date.
Whilst we found no breaches of regulations, the provider should:
- Continue to embed the Standard Operating Procedures within the dispensary.
- Continue to support the infection control lead nurse to undertake planned training which was postponed due to COVID-19.
- Continue with plans to strengthen the monitoring arrangements for patients prescribed specific medicines.
- Confirm in writing, information given to patients verbally in response to complaints raised.
- Continue work to include an audit trail when policies were reviewed.
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