Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Mauldeth Medical Centre, 112 Mauldeth Road, Manchester M14 6SQ on 7 July 2015. During the inspection we identified breaches of Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010 Management of Medicines and Regulation 17 HSCA (RA) Regulations 2014 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The breaches resulted in the practice being rated as requires improvement for being safe, effective and well-led and good for being caring and responsive. Consequently the practice was rated as requires improvement overall. The full comprehensive report on the July 2015 inspection can be found by selecting the ‘all reports’ link for Mauldeth Medical Centre on our website at www.cqc.org.uk.
At this announced comprehensive inspection on 10 April 2017 we checked whether improvements had been made since our inspection in February 2016.
We found improvements had been made in respect of;
The practice manager had attended a leadership course and now carried out management and administration duties only.
Systems relating to recording and sharing information and monitoring outcomes for patients had been improved since the last inspection.
At this inspection carried out on 10 April 2017 our key findings were as follows:
Clinical audits were carried out; however we did not see any systems in place to analyse and review these audits.
There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
The practice policies and procedures had been reviewed within the last 12 months, these were in line with current guidance and available to staff.
- Staff were aware of current evidence based guidance. Staff had access to an on-line training programme to provide them with the skills and knowledge to deliver effective care and treatment.
- Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
Patients we spoke with said they generally found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However, some patients did report difficulties booking appointments by telephone.
There was a clear leadership structure and staff felt supported by management. Each GP and senior member of staff had defined clinical responsibilities in different areas such as child protection and adult safeguarding, elderly care and information governance.
- The practice sought feedback from staff and patients, which it acted on.
- The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
The areas where the provider must make improvement are:
Ensure there is an effective recall system for patients with long term medical conditions and for patients prescribed specific high risk medicines in order to undertake appropriate health checks in accordance with NICE guidance.
The practice must review their arrangements for clinical audit to demonstrate audits comprise of two or more cycles in order to monitor improvements to patient outcomes.
The areas where the provider should make improvement are:
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice