Stenhouse Medical Centre

We carried out an announced inspection at Stenhouse Medical Centre on 13 July 2022. Overall, the practice is rated as Good.

The ratings for each key question:

Safe - Good

Effective - Good

Caring – Not inspected

Responsive – Not inspected

Well-led - Good

Following our previous inspection on 13 July 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Stenhouse 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.

This inspection was a focused review of information:

• We reviewed the key questions of safe, effective and well-led in line with our inspection methodology.
• The ratings for the caring and responsive key questions were carried forward from our previous inspection as we had no concerns to indicate that these needed to be reviewed.

How we carried out the inspection

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 inspections differently.

This inspection was carried out in a way which enabled us to reduce the amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider

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

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 adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• 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:

• Complete safeguarding level two training for all non-clinical staff who have contact (however small) with children, young people and/or parents/carers or adults who may pose a risk to children.
• Ensure all non-clinical staff complete training on sepsis awareness, and source additional training for the designated practice infection control lead.
• Continue to collate evidence of the practice team’s immunisation status.
• Implement an updated and effective recall system for patients.
• Develop a process that provides historic medicines alerts to be kept under review.
• Improve staff recruitment records by checking qualification certificates for all staff.
• Continue to address the backlog of patient notes requiring summarisation.

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