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Mauldeth Medical Centre Good

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 Mauldeth Medical Centre 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 Mauldeth Medical Centre, you can give feedback on this service.

Review carried out on 31 December 2019

During an annual regulatory review

We reviewed the information available to us about Mauldeth Medical Centre on 31 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 25/04/2018

During an inspection looking at part of the service

This practice is rated as Good overall. (Previous inspection April 2017 – Good)

We carried out an announced comprehensive inspection at Mauldeth Medical Centre on 10 April 2017. The overall rating for the practice was good with key question Effective rated as requires improvement. At that inspection we found improvements were needed as the practice had failed to implement a safe system of patient recall for those prescribed high risk medicines and systems to monitor the effectiveness of clinical audit and other quality improvements to improve patient care were not in place. We issued two requirement notices in respect of Safe care and treatment and Good governance; regulations 12 and 17 HSCA (RA) Regulations 2014. We identified one other area the practice should develop and this was to identify patients who were carers so services could be offered to meet their needs.

The full comprehensive report on the April 2017 inspection can be found by selecting the ‘all reports’ link for Mauldeth Medical Centre on our website at

This inspection was a focused visit to the practice on 25 April 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 10 April 2017. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

This focused inspection visit identified improvements had been made in service delivery for key question Effective and this is now rated good.

Our key findings were as follows:

  • At our previous inspection in April 2017 we found systems to monitor patients with chronic long term health conditions or monitor those patients prescribed high risk medicines were not effectively established. At this inspection there was clear evidence available to demonstrate the practice had reviewed its systems and had implemented action to ensure continuous ongoing monitoring of patients with a long term condition and those prescribed high risk medicines.

  • The previous inspection identified that clinical audit was not linked to patient outcomes. At this inspection visit we reviewed a number of audits including those for high risk medicine, asthma control and one for end of life. These audits demonstrated the practice linked the quality improvement work with patient outcomes.

  • At the inspection in April 2017 we identified that some patients’ electronic records had not been correctly coded. Following that inspection the practice undertook a data cleansing exercise of the patient electronic system and one GP partner undertook the lead role for monitoring the patient electronic system to ensure it was accurate.

  • The previous inspection identified that some performance indicators for diabetes and cervical cytology were below the local and national averages. The practice was implementing action to address these issues including providing additional training for one practice nurse to develop their expertise in the management of diabetes and one practice nurse had been trained in cervical cytology.

The areas where the provider should make improvements are

  • Continue to implement action to improve the practice performance in the management of patients with diabetes and cervical cytology.

  • Continue to promote the practice carers’ register and encourage patients to identify themselves as carers.

Inspection carried out on 10 April 2017

During a routine inspection

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;

Safe

  • There was documentary evidence that emergency medicines were checked to ensure they were in date and fit for use.

  • The process for managing medical alerts had been improved.

Effective

  • The practice had developed a policy in relation to coding / summarising patient records. However, we did not see an effective process in place to quality assure coding work completed.

Well-led

  • 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:

  • Review arrangements in place to ensure that patients with caring responsibilities are identified, so their needs are identified and can be met.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 7 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Mauldeth Medical Centre on the 7 July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective and well led services. It was good for providing a caring and responsive service.

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

  • The practice had a system in place for reporting, recording and monitoring significant events.
  • Systems for receiving and monitoring alerts and safety notifications needed to be improved.
  • Staff were trained in safeguarding procedures.
  • Improvements were needed to the way infection control was managed.
  • Patients told us they were treated with dignity and respect. They spoke highly of the GPs and other staff and described them as helpful and the GPs as excellent.
  • Emotional support was provided to patients who experienced a bereavement.
  • The practice manager acted as a cancer champion to support patients with a diagnosis of cancer.
  • Some patients felt they had to wait a long time for an appointment, this being seven to ten days.
  • The staff spoken with said they were very happy working at the practice. They said they were kept informed of matters relating to their role and the running of the practice.
  • There was a lack of clarity about the overall governance process in the practice. We found that some systems needed to be more robust and the training provision needed to be improved.

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

Importantly, the provider must:

  • Ensure medicines are managed safely including improvements to the process for dealing with medicine alerts.
  • Ensure governance systems bring about improvements to the service.

In addition the provider should:

  • Record the necessary information about any significant events that take place.

  • Provide training for staff who act as a chaperone, and record the name of the chaperone used in patients’ notes.
  • Improve the management of infection control.
  • Establish a more robust appointment recall system.
  • Complete full cycles of audits and create a log of audits with review dates.
  • Improve the quality of coding and develop a coding / summarisation policy. Also, provide staff with training in this area of work if necessary.
  • Keep an accurate record of staff training and develop a training matrix to monitor staff training for the forthcoming year.
  • Ensure test results are reviewed by a clinically competent professional.
  • Provide all staff with training in the Gillick competencies.
  • Provide information in different languages to support patients whose first language is not English.
  • Improve the uptake of cytology testing.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice