We carried out an announced inspection at Mayflower Medical Group- Stirling Road Surgery on 21 and 26 May 2021. Overall, the practice is rated as Inadequate
Safe - Inadequate
Effective - Inadequate
Caring – Requires Improvement
Responsive – Inadequate
Well-led - Inadequate
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
- A pre site visit staff questionnaire.
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 Inadequate overall and inadequate for Safe, Effective, Responsive and Well Led and all population groups. We have rated Caring as Requires Improvement.
We rated the practice as inadequate for providing Safe services because:
- We found the practice’s system for managing patient and drug safety alerts did not ensure medicines were prescribed safely. We found the practice had not properly actioned any of the three alerts we reviewed. There was no evidence to show the practice had taken action to protect patients from avoidable harm.
- The practice did not evidence a safe system to ensure patients on high risk medicines were appropriately managed in a timely way.
- The practice did not fully evidence that patients had a structured and comprehensive medicine review. We identified reviews had been coded on the clinical system but there was no evidence in the clinical records of a structured medicine review or consultation with the patient.
- The practice did not have a system to learn and make improvements when things went wrong.
We rated the practice as inadequate for providing Effective services because:
- The practice could not provide assurances that patients were coded appropriately and that patients received necessary monitoring.
- The practice could not provide assurances that patients presenting with symptoms indicating a serious illness, would be followed up in a timely way.
- There was limited monitoring of the outcomes of care and treatment.
- There was no evidence to demonstrate Clinical audits were used to drive continuous improvement.
We rated the practice as requires improvement for providing caring services because:
- Feedback from patients raised concerns about staff attitude and access to timely information.
- There were not effective processes to ensure staff remained qualified and competent for their role.
We rated the practice as inadequate for providing responsive services because:
- Patients experienced difficulties accessing care and treatment
- Complaints were not used to drive improvements at the practice.
We rated the practice as inadequate for providing well led services, because:
- There was limited evidence that there was a cohesive system of governance in place to drive change to improve how the service was delivered including ensuring that a safe and effective service was provided
- The practice did not have clear and effective processes for managing risks, issues and performance.
We found three breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients with an effective programme of monitoring and support to meet their needs.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Establish effective systems to ensure that staff had received appropriate, support, training, professional development, supervision and appraisal to enable them to carry out the duties they are employed to perform.
The provider should:
- Ensure that safeguarding alerts are put on records of parents of children with safeguarding concerns to highlight any issues when a parent attends.
- The provider should look for ways to improve outcomes for patients with long-term conditions.
- The practice should continue to monitor and improve how patients could access the cervical screening programme.
- The provider should look for ways to identify carers to ensure support was offered.
I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to
varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.
Special measures will give people who use the service the reassurance that the care they get should improve.
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