We carried out a review of the data available to us about Mandalay 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 Mandalay Medical Centre, you can give feedback on this service.
We carried out an announced comprehensive inspection at Mandalay Medical Centre on 4 November 2016. The overall rating for the practice was good, with a rating of requires improvement in the safe domain. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Mandalay Medical Centre on our website at www.cqc.org.uk.
We then carried out an announced focused inspection 10 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 November 2016. In this inspection we found that some improvements had been made but we identified areas that needed further improvement. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for Mandalay Medical Centre on our website at www.cqc.org.uk.
This inspection was a desk based review to confirm the practice had made the required improvements from the previous inspection.
Overall the practice is now rated as good in all domains.
Our key findings were as follows:
Legionella checks were carried out on water outlets set out in the legionella risk assessment. The practice had taken action to ensure themselves that the temperatures recorded were acceptable.
Fire drills were now being carried out by the practice and documented. All staff had received fire safety awareness training.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Mandalay Medical Centre Health Centre on 4 November 2016. The overall rating for the practice was good, with a rating of requires improvement in the safe domain. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Mandalay Medical Centre on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 10 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 November 2016. This report covers our findings in relation to those requirements.
Overall the practice is rated as good. The rating for the safe domain remains requires improvement.
Our key findings were as follows:
There was a robust recruitment process and all required information for staff was held.
Staff had been informed of the procedure to follow when chaperoning patients.
Staff had an appraisal within the last 12 months.
A health and safety and fire safety risk assessment had been carried out and all required checks were regularly performed.
Arrangements were ongoing for staff to receive face to face fire safety training.
No fire drill had ever taken place at the practice.
Although regular legionella checks were carried out these were not for all required water outlets and advice or action had not been taken when water was below the minimum safe temperature.
The area of practice where the provider needs to make improvements is:
The provider must ensure care and treatment is provided in a safe way to patients.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Mandalay Medical Centre on 4 November 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvement are:
The provider must ensure all the required information is available for new employees prior to them starting work.
The provider must assess the risks to the health and safety of patients by having a health and safety risk assessment, fire risk assessment and legionella risk assessment.
The provider must ensure all medical devices are within their expiry dates and disposable privacy curtains are changed at the correct frequency.
In addition the provider should:
Ensure all staff are aware of the procedure to follow when chaperoning.
Continue with their plans to bring appraisals up to date for all staff.
Chief Inspector of General Practice