Archived: Stoneycroft Medical Centre

We carried out an announced inspection at Stoneycroft Medical Centre on 2 and 3 August 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective – Requires improvement

Caring – Good

Responsive – Requires improvement

Well-led - Inadequate

Why we carried out this inspection

The practice was registered with us on 5 August 2019 and has not been inspected since this registration. This inspection was a comprehensive inspection as part of our inspection programme and it covered all key questions.

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 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
• Speaking to patients during the 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 requires improvement overall.

We have rated this practice requires improvement for providing safe services. This is because:

• Recruitment checks were not always carried out in accordance with regulations.
• There were gaps in systems to assess, monitor and manage risks to patient safety.
• The practice did not have an effective system to learn and make improvements when things went wrong.

We have rated this practice requires improvement for providing effective services. This is because:

• There was no evidence of quality improvement activity at the practice.
• The practice did not have an effective programme of learning and development.
• The practice did not demonstrate that appraisal and supervision took place regularly.

We have rated this practice good for providing caring services. This is because:

• Staff treated patients with kindness, respect and compassion and involved them in decisions about their care.

We have rated this practice requires improvement for providing responsive services. This is because:

• Patient feedback showed a dissatisfaction with access to the service.
• Systems and processes to manage complaints were not effective.
• There were not enough suitably qualified staff to meet the needs of all patients.

We have rated this practice inadequate for providing well – led services. This is because:

• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• Leaders were not visible or approachable.

We found four breaches of regulations. The provider must:

• Ensure patients are protected from abuse and improper treatment.
• Ensure all premises and equipment used by the service is fit for use.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The provider should:

• Continue to improve the uptake of cervical screening.
• Invite patients to feedback about the service.
• Apply to make the necessary changes to their registration to accurately reflect the number of GP partners at the practice.

The service has been rated as inadequate for being well-led and have six months to improve. We will inspect it again within six months. If the service is rated as inadequate for a key question at the second inspection, it will be placed in special measures.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services