The Care Quality Commission
  • Doctor
  • GP practice

The Mounts Medical Centre

Overall: Requires improvement read more about inspection ratings

Campbell Street, Northampton, Northamptonshire, NN1 3DS (01604) 632117

Provided and run by:
The Mounts Medical Centre

All Inspections

7 & 8 November 2023

During a routine inspection

We carried out an announced comprehensive inspection at The Mounts Medical Centre between 6 and 8 November 2023. Overall, the practice is rated as requires improvement.

Safe - good

Effective - requires improvement

Caring - requires improvement

Responsive - requires improvement

Well-led – good.

During the inspection process, the practice highlighted efforts they are making to improve outcomes for their population. The effect of these efforts is not (yet) reflected in verified outcomes data. As such, the ratings for this inspection have not been impacted. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.

Why we carried out this inspection

Following our previous inspection on 16 May 2017, the practice was rated good overall and for all key questions. We carried out this inspection in line with our inspection priorities. Through our monitoring activities we identified concerns that met the threshold for carrying out an inspection.

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

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit of the practice and branch site.

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 requires improvement overall.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Where we identified gaps in systems and processes, the practice responded in a timely manner to reduce risks to patients and staff.
  • The practice learned from incidents, events and complaints and ensured learning was shared amongst the staff team.
  • We found the premises were well maintained, appeared visibly clean and tidy and there were appropriate infection prevention and control arrangements in place.
  • Patients received effective care and treatment that met their needs. Where areas of improvement were identified, the practice took timely action to monitor the effectiveness of patient care.
  • Staff were aware of the diverse and complex needs and demands of their patient population. They dealt with patients with kindness and respect and supported them to overcome barriers to receiving care where possible.
  • The way the practice was led and managed, promoted the delivery of high-quality, person-centre care.
  • Leaders took a proactive approach to recruitment of staff despite the challenges they faced with staff retention.
  • The culture of the practice drove the delivery and improvement of high-quality, person-centred care, with staff sharing a commitment to supporting a challenging and vulnerable patient population.

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

  • Complete work in progress to maintain records of staff vaccination and immunity status.
  • Improve the uptake of childhood immunisations and cervical cancer screening.
  • Continue to embed improved systems for recording creatinine clearance levels and reviewing patients prescribed medicines to support thyroid function.
  • Implement repeat cycle audits to monitor improvement and further improve quality.
  • Continue to improve outcomes for patient satisfaction results and monitor the impact of changes that have been implemented.
  • Actively monitor and improve patient access to the practice.
  • Take steps to promote and recruit patients to participate in the Patient Participation Group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

27 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Mounts Medical Centre on 7 October 2015. The overall rating for the practice was Good however a breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to:

  • Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.

The full comprehensive report of the inspection on 7 October 2015 can be found by selecting the ‘all reports’ link for The Mounts Medical Centre on our website at www.cqc.org.uk .

This inspection was a desk-based focused follow up inspection carried out on 27 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 7 October 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as ‘Good’.

From the inspection on 7 October 2015, the practice was told they must:

  • Strengthen recruitment procedures to ensure persons employed met the conditions specified in Schedule 3 for the purposes of carrying out the regulated activities. Specifically this was because appropriate pre-employment checks such as the Disclosure and Barring checks (DBS) had not been made on some clinical staff that required this check.

We also told the practice that they should make improvements to the follows areas:

  • To the way they advertised how patients could complain, the availability of translation services and the support available for people who cared (carers) for others.
  • To the way they appraised staff. This was because at the time of the inspection the practice had just established the management structure and not all staff had been appraised.
  • To the fire risk assessment and action plans so a map of the practice was available to identify potential exit routes in the event of a fire.

Our key findings were as follows:

  • We found that on 27 March 2017 the practice had made the necessary changes to their recruitment procedures and was now compliant with the requirements of Schedule 3 of Regulation 19 Health and Social Care Act (Regulated Activities) Regulations 2014, Fit and proper persons employed.
  • During this inspection the practice confirmed that wall posters together with a moving ticker tape display on the patient information screen in the waiting area now gave the required information about how patients could complain, the availability of translation services and the support available for people who cared (carers) for others.
  • During this inspection the practice confirmed that their appraisal process was now fully established and all staff has had an appraisal in the past 12 months.
  • During this inspection the practice confirmed that they had a practice map available and accessible, this included exit routes clearly highlighted and held in the fire safety folder.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Mounts Medical Centre on 7 October 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed with the exception of recruitment where we found appropriate checks had not been carried out.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However, there were areas where the provider needed to make some improvements. Importantly the provider must:

  • Ensure robust recruitment procedures are established and followed prior to employment of staff.

In addition, the provider should:

  • Ensure information regarding the complaints procedure, translation services and carers is readily available.

  • Ensure that staff appraisals are completed for all staff.

  • Ensure that all actions are completed related to the fire risk assessment.

  • Ensure the arrangements for business continuity in the event of a major event are updated.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice