You are here

Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Maylands Health Care on 9 September 2021. 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 Maylands Health Care, you can give feedback on this service.

Inspection carried out on 16 June 2021

During an inspection looking at part of the service

We carried out an announced review at Maylands Health Care on 16 June 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 22 July 2019, the practice was rated Good overall and for all key questions except Responsive, which was rated as Requires Improvement as were all population groups.

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

Why we carried out this review:

This review was a focused review of information without undertaking a site visit inspection to follow up on the areas identified as requiring improvement at our last inspection. The Responsive key question was reviewed to ensure that appropriate action had been taken by the provider, to meet the fundamental standards of health and social care.

How we carried out the review:

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 reviews differently.

This review was carried out in a way which enabled us to request information from the provider without the needs for a site visit. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Requesting evidence from the provider
  • Liaising with the management team as appropriate.

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 Good overall and Good in the Responsive key question and for all population groups.

We found that:

  • 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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue to monitor and embed the new systems and ways of working to continue to improve patient access by telephone.

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

Inspection carried out on 22 July to July 22 2019

During a routine inspection

We carried out an announced comprehensive inspection at Maylands Medical care on 22 July 2019, to follow up the breaches of inspection found in the inspection of 14 November 2018 .

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 rated the practice as requires improvement for providing responsive services because:

  • We found the practice had made improvements and increased the number of available appointments following the inspection on the 14 November 2018. However, the system for contacting the practice by telephone to make an appointment restricted patient access to the practice.

This has impacted all population groups and so we have rated all population groups as requires improvement.

We rated the practice as good for providing safe, effective, caring and well led services because:

  • The practice had made significant improvement to the practice in response to the previous inspection.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Complaints were listened and responded to and used to improve the quality of care.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice learned and made improvements when things went wrong.
  • Staff worked together and with other organisations to deliver effective care and treatment.

The areas where the provider must make improvements are:

Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences in regard to accessing telephone appointments.

The areas where the provider should make improvements are:

  • Review the emergency drugs and put in place a risk assessment to demonstrate the reasons when medicines are not included.
  • Review the clinical supervision, to ensure it includes the regular review of the clinicians patient notes.
  • Review the need for a Disclosure and Barring Check for volunteers where there is patient contact.

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.

Inspection carried out on 14 November 2018

During a routine inspection

This practice is rated as Requires improvement overall. (Previous inspection 4 February 2016 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

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 Maylands Health Care on 14 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice worked in partnership with patients and external partners to successfully sustain service delivery for its 14,700 patients from various premises due to a serious flood over eight months from July 2016 to February 2017. During this time, the premises was up to 60cm underwater and drying out for a further three months until spring 2017. Staff and patients explained the practice was still recovering from this major incident that affected business as usual including improving patient access, strategy and oversight, and routine staff checks, annual appraisals and training.
  • The practice systems to manage safety and risk were variable. Several risk assessment processes had not been undertaken, were overdue or not followed up. However, patient safety alerts and safety incidents were managed effectively to improve safety.
  • 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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use but reported that they were not always able to access care when they needed it.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas of practice where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure care and treatment is provided in a safe way to patients.

The areas of practice where the provider should make improvements are:

  • Review and improve insight and understanding of clinical data and elements of patients coding on records.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 04 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Maylands Health Care on 04 February 2016. 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 a system in place for reporting, recording and learning from significant events.

  • Risks to patients were assessed and well managed.

  • 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.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Patients said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

  • Patients said they could get an appointment when they need one, including same day urgent appointments.

  • Information about services and how to complain was available and easy to understand.

  • 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.

  • The provider was aware of, and was developing policy and practice to ensure that, it complied with the requirements of the Duty of Candour.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 20 June 2014

During a routine inspection

The inspection team consisted of a CQC inspector, a GP and a practice manager. As part of this routine inspection, we followed up on information received alleging there were no disclosure checks for staff. We spoke to the practice manager, two partners, a trainee GP, two nurses, one health care assistant and administration staff. We spoke to 18 patients. Sixteen out of 18 were happy with the care they received. Two out of 18 told us more could be done to manage their multiple long term conditions and ensure that different health care professionals coordinated care and medication reviews.

We found care was assessed and planned according to individuals� medical conditions. Referrals were made in a timely manner and there were systems in place to follow up referrals made as well as asking the patient to notify the practice if they had not received any confirmation that a referral had been made. Home visits were available for those who needed them and people with palliative care needs were visited weekly.

The practice was accessible via wheelchair, although electric scooters were to be left at reception. Patients told us that getting an appointment over the phone was usually a problem and sometimes they had to wait for over three weeks.

Staff were aware of safeguarding protocols and how to report concerns.

There were systems in place to monitor the quality of care provided. Staff were supported to do their work by appraisals, regular team meetings and feedback on both good practice and areas for development. However, there were gaps in training of administrative staff.