St Paul's Medical Centre

We carried out an announced inspection at St Paul’s Medical Centre on 16 June 2022. Overall, the practice is rated as Good.

The key question ratings are as follows:

Safe - Good

Effective – Good

Caring – Good - Carried forward from the last inspection in March 2016.

Responsive – Good - Carried forward from the last inspection in March 2016.

Well-led – Good

Following our previous inspection on 30 March 2016, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Paul’s Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a rating inspection to check the provider was complying with the regulations under the Health and Social Care Act 2008. We inspected three key questions to determine if the service is safe, effective and well led. We also collected evidence around access to the service in the responsive key question.

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:

• Conducting staff interviews remotely using video conferencing;

• Completing clinical searches on the practice’s patient records system and discussing findings with the provider;

• Requesting evidence from the provider for remote analysis;

• Further communications for clarification.

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;

• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• The provider had established governance systems and processes to provider oversight of the operations of the practice,
• The practice team engaged fully in the inspection process and staff provided positive feedback on their experience of working at the practice and the support from leaders;
• Patients received effective care and treatment that met their needs however the monitoring of high-risk medicines was in need of review for some patients;
• The practice was actively engaged in quality improvement and clinical audit activities and had identified areas for development to ensure continuous improvement;
• 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 subject to the available resources of the practice;
• Emergency equipment and medicines were in place to ensure an appropriate response to a medical emergency;
• Systems were in place to manage infection, prevention and control.

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

• Review the management of patients prescribed high-risk drugs to ensure monitoring is being completed in accordance with recommended best practice guidelines;
• Remove blank prescription forms from printer trays, lock away when not in use or out of hours and ensure accurate records are maintained relating to the allocation and return to stock of prescriptions;
• Record the level of disclosure and barring service check undertaken for staff to ensure a clear audit trail;
• Update safeguarding procedures to include the correct contact numbers;
• Ensure the fire procedure (emergency plan) is updated to include the details of the fire marshals.

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