The Care Quality Commission
  • Doctor
  • GP practice

Montpelier Health Centre

Overall: Good read more about inspection ratings

Bath Buildings, Bristol, Avon, BS6 5PT (0117) 942 6811

Provided and run by:
Montpelier Health Centre

All Inspections

3 and 9 September 2021

During a routine inspection

We carried out an announced inspection at Montpelier Health Centre on 3 and 9 September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective -Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 26 June 2019, the practice was rated Requires Improvement overall and for the key questions of providing effective services and well-led services. We identified a breach of the Regulation 17 (Good Governance) and issued a requirement notice. The practice needed to establish and operate effective quality assurance systems and processes to ensure compliance with the regulations.

In particular we found:

  • There was not effective oversight of staff training. Not all staff were up to date or had received training in line with practice policy and national guidance.
  • Systems to ensure policies were consistently followed, were not embedded.
  • Practice systems for exception reporting did not ensure this was always appropriate and that patients received necessary care and treatment.
  • Processes to mitigate risks to patients and staff were not embedded. For example, systems to monitor blank prescriptions stationery.

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

Why we carried out this inspection

This inspection a comprehensive inspection, which included a site visit. The key questions inspected included:

  • Is the service safe?
  • Is the service effective?
  • Is the service well-led?

We also checked if the practice met the compliance with the Regulation 17 (Good Governance).

Ratings from the caring and responsive key questions were carried from our inspection in June 2019, when these both key questions were rated as good.

How we carried out the inspection/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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum 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
  • 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 Good overall and good for all population groups.

We found that:

  • The requirement notice issued following our inspection in June 2019 had been met and governance systems were effective and ensured the health safety and welfare of patients.
  • 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. 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:

  • Consider maintaining records for all cleaning activities carried out at the practice, in particular cleaning of clinical rooms between patient consultations.

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

26 Jun 2019

During a routine inspection

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. We carried out an inspection of this service due to the length of time since the last inspection as well as the information received during our review which indicated that there may have been a significant (either deterioration or improvement) to the overall quality of care provided since the last inspection. Due to these reasons we conducted a full comprehensive inspection of this service.

This inspection focused on the following key questions:

  • Is the service safe?
  • Is the service effective?
  • Is the service caring?
  • Is the service responsive?
  • Is the service well led?

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing effective services.

We found that;

  • Practice systems did not ensure consistently appropriate exception reporting or give assurances that all patients received appropriate care and treatment.
  • Staff training was not delivered in line with practice policy and oversight of training was not embedded.

These areas affect all population groups so we have rated all population groups as requires improvement.

We rated the practice as requires improvement for providing well led services.

We found that;

Governance systems did not clearly demonstrate an embedded programme of assessment, monitoring or mitigation of risk. For example:

  • Practice processes to record and act on medicine alerts were not always comprehensive.
  • Practice processes to mitigate risk to patients and staff was not always effective.

We rated the practice as good for providing safe, caring and responsive services.

We found that;

  • The practice provided clinical care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are;

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are;

  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to improve uptake of cervical smears.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Rosie Benneyworth

Chief Inspector of PMS and Integrated Care

2nd of December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Montpelier Health Centre on 2 December 2014.

We rated the practice as good for providing well-led, effective, safe, caring and responsive services. It was also good for providing services for older people, people with long-term conditions, mothers, babies, children and young people, working-age population and those recently retired, people in vulnerable circumstances who may have poor access to primary care and people experiencing poor mental health.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and knew how to report incidents and near misses. Information about safety measures were recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about the services provided and how to complain was available and easy to understand.
  • The practice had good facilities and was equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted upon.
  • The practice was a GP training practice. There was a practice focus on the development of individuals and involvement in research projects.

In addition the provider should:

  • the practice should ensure that all relevant documentation for the recruitment of new staff is retained to show a robust and safe process was carried out.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice