• Doctor
  • GP practice

The Margaret Thompson Medical Centre

Overall: Requires improvement read more about inspection ratings

105 East Millwood Road, Liverpool, Merseyside, L24 6TH (0151) 425 3331

Provided and run by:
The Margaret Thompson Medical Centre

All Inspections

24 August 2022

During a routine inspection

We carried out an announced comprehensive at The Margaret Thompson Medical Centre on 17 and 24 August 2022. Overall, the practice is rated as requires improvement.

The key questions are rated as:

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

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

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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.

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 have rated this practice requires improvement for providing safe services. This is because:

The practice is rated as requires improvement for providing safe services. This is because:

  • There was limited use of systems to record and report safety concerns, incidents and near misses. Some staff were not clear how to do this.
  • The provider did not have oversight of all referrals to secondary care.
  • Historical safety alerts were not always reviewed to ensure actions were followed.

We have rated this practice requires improvement for providing effective services. This is because:

  • Not all staff had undertaken the relevant training updates to do their job. The learning needs of staff were not fully understood.
  • There were gaps in management and support arrangements for staff as appraisal, supervision and professional development was not routinely offered.

We have rated this practice good for providing caring services. This is because:

  • The provider supported patients with kindness, dignity and respect.

We have rated this practice good for providing responsive services. This is because:

  • Patients were able to access care and treatment within an appropriate timescale for their needs.

We have rated this practice requires improvement for providing well led services. This is because:

  • Leaders were not always aware of the risks, issues and challenges in the practice.
  • There has been no recent review of the governance arrangements, the strategy, or plans.
  • There was a lack of effective governance systems for managing risk, issues and performance.

We found two breaches of regulations. The provider must:

  • Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards of care and treatment.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The provider should:

  • Continue with the replacement schedule for clinic room flooring and chairs.
  • Review and improve the uptake of cervical cancer screening and childhood immunisations.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

5 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 3 March 2016. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

  • Regulation 18 HSCA (RA) Regulations 2014 Staffing.

We undertook this focused inspection to check that they had followed their action plan to demonstrate how they would meet the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Margaret Thompson Medical Centre on our website at www.cqc.org.uk

Our key findings were as follows:

  • The practice had addressed the issues identified during the previous inspection. Staff had received mandatory training required and a schedule of appraisals was in place.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Margaret Thompson Medical Centre on 3 March 2016. Overall the practice is rated as good. The practice is rated as good for providing safe, caring, responsive and well led services. The practice requires improvement in providing effective services due to shortfalls in staff training and appraisal systems.

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

  • The practice is situated in a large purpose built health centre. The practice was clean and had good facilities including disabled access, translation services and a hearing loop.

  • There were systems in place to mitigate safety risks including analysing significant events and safeguarding.
  • The practice was aware of the challenges that a very economically deprived area presented and all staff were passionate about making a difference to patients’ lives.

  • Patients’ needs were assessed and care was planned and delivered in line with current legislation.

  • 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. The practice sought patient views about improvements that could be made to the service; including having a patient participation group (PPG) and acted, where possible, on feedback.
  • Many of the staff had worked at the practice for a long time and knew the patients well. Staff worked well together as a team and all felt supported to carry out their roles but training and appraisals were not up to date.

There was an example of outstanding practice:

  • The practice had additional safeguards to be prepared for a medical emergency. The medical emergency equipment was checked on a daily basis and emergency medications were checked on a monthly basis by two staff members simultaneously to reduce the risk of errors. When any emergency had occurred in the past, this had been discussed and actions taken to improve. For example, the practice recognised that the response times of ambulances attending could vary significantly. Therefore, there was a risk if a patient needed high flow oxygen over a longer period of time than expected, more than one oxygen cylinder would be required and the practice had purchased additional oxygen to reduce the risk of running out.

However, there were areas where the provider must make improvements.

The provider must:

  • Ensure all members of staff receive mandatory training especially fire safety awareness and fire drills.

  • Ensure all members of staff receive regular appraisals.

The provider should:

  • Carry out an analysis of significant events periodically in order to identify any trends to help make improvements.

  • Have a monitoring system in place for any blank prescriptions still in stock.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice