The Care Quality Commission
  • Doctor
  • GP practice

Monarch Medical Centre

Overall: Good read more about inspection ratings

65 Cross Lane, Radcliffe, Manchester, Greater Manchester, M26 2QZ (0161) 723 0123

Provided and run by:
Monarch Medical Centre

All Inspections

01/07/2020

During an inspection looking at part of the service

We last inspected Monarch Medical Centre on 14 May 2019. The practice was rated as good for being safe, effective, caring and responsive, and requires improvement for being well led. This resulted in an overall rating of good. We found that the provider had breached one regulation of the Health and Social Care

Act 2008: Regulation 17 Good Governance. We issued a Requirement Notice in relation to Regulation 17, Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The report on this inspection can be found on our website at: https://www.cqc.org.uk

We carried out this focused desk-based review of Monarch Medical Centre on 1 July 2020. The purpose of this review was to determine if the services provided by the practice were now meeting the legal requirements and regulations under Section 60 of the Health and Social Care Act 2008. We found that improvements had been made and the provider was no longer in breach of the regulations.

During this desk-based review we looked at a range of documents submitted by the practice to demonstrate how they had met the requirements notice. The documents looked at included:

  • Calibration / maintenance and PAT testing policy and test certificates for clinical equipment.
  • Induction training programmes for clinical and non clinical staff.
  • A revised policy for managing safety alerts.
  • A revised cancer care review protocol.
  • A staff training plan for READ coding.
  • Information about the management of complaints.

During this desk-based review we looked at the following question:

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

  • Equipment held in the doctors’ bags was calibrated and tested for its safety.
  • There was a staff induction programme for clinical and non clinical staff.
  • There was a revised and updated system for managing safety alerts.
  • A revised cancer care review protocol had been introduced.
  • A staff training plan for READ coding was in place and interim training was provided by the practice manager.
  • The complaint procedure had been updated. Complaint investigations were carried out and patients had received a written response to their complaint. There was evidence of complaints being monitored for the purpose of learning.

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

During a routine inspection

We carried out an announced comprehensive inspection at Monarch Medical Centre on 14 May 2019 as part of our inspection programme.

At the last inspection in September 2018 we rated the practice as requires improvement for providing safe services because:

  • Guidance was not available about how to assess and manage sepsis in adults.
  • 2-week referrals were not monitored and audited.
  • A risk assessment was not completed to identify a list of medicines that were not suitable for the practice to stock.
  • Emergency medicines were not monitored to ensure their safe keeping.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • We found that while the way the practice was led and managed promoted the delivery of good care, some systems required improvement to ensure patient outcomes were fully met.

We found a breach of regulations. The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

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

20 March 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous inspection May 2016– Good)

The key questions are rated as:

Are services safe? – requires improvement

Are services effective? – requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – requires improvement.

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – requires improvement

People with long-term conditions – requires improvement

Families, children and young people – requires improvement

Working age people (including those recently retired and students – requires improvement

People whose circumstances may make them vulnerable – requires improvement

People experiencing poor mental health (including people with dementia) - requires improvement

We carried out an announced comprehensive inspection at Monarch Medical Centre

on 20 March 2018 as part of our inspection programme.

At this inspection we found:

  • Safeguarding policies and procedures were in place. However, we found the procedures needed to be updated further to reflect current guidelines.
  • Overall, the practice had systems to manage risk so that safety incidents were less likely to happen. When incidents happened, the practice learned from them and improved their processes. However, we found that some improvements were needed to these systems as clinical discussions held by GPs were not routinely recorded to ensure good communication.
  • Medicines were generally well managed, although improvements could be made to the way prescriptions were stored.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Data showed that that clinicians assessed patients’ needs and delivered care and treatment in line with current legislation.
  • The practice had a programme of quality improvement activity and completed clinical audits although they had not been reviewed to test the effectiveness and appropriateness of the care provided.
  • Staff spoken with confirmed they received regular training; however the training records were not up to date to confirm this.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Interpretation services were available for patients who did not have English as a first language.
  • Generally patients found the appointment system easy to use and reported that they were able to access care when they needed it. Some patients reported they found it difficult to book an appointment.
  • Most of the 26 patient Care Quality Commission comment cards we received were positive about the service experienced.
  • Leaders had the capacity and skills to deliver good care. They aspired to provide safe, good quality and compassionate care. However, some systems were not effective for monitoring and reviewing policies and procedures and ensuring good record keeping and communication within the staff team
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • A record should be kept of discussions held about patients’ health care issues.

  • Information should be provided in different languages to support patients who do not have English as a first language.

  • Regular fire drills should be carried out.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

19/05/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Monarch Medical Centre on 19 May 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring, responsive and safe services. It was also good for providing services for the populations groups we rate.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand, however there was no evidence of the system being put into practice.
  • Patients provided varied feedback on accessing appointment, with a number of patients reporting difficulties getting through to the practice by telephone, however patients reported when they got appointments these were convenient.
  • 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should

  • Ensure all staff receives regular refresher safeguarding training.
  • Ensure staff acting as chaperones receive appropriate training and procedures follow professional guidance.
  • Ensure none clinical staff have access to appraisals on an annual basis.
  • Have systems in place to formally gather and act on the views of patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 October 2013

During a routine inspection

During our inspection we spoke with the practice manager, two doctors, the practice nurse and two receptionists. We also spoke with five patients.

Patients told us they were given enough privacy during their visits to the practice and were treated respectfully by staff. They all spoke positively about the practice. Their comments included 'They're like old fashioned doctors here. I would always recommend here'.

We saw that all areas of the practice were clean. Protective clothing such as disposable gloves were available and liquid hand wash, alcohol hand gel and paper towels were available in all consultation rooms.

The provider carried out the required checks for all staff prior to them starting work.

The doctors carried out patient surveys and clinical audits. The practice manager told us they carried out regular informal checks on the quality of the service they provided.