This practice is rated as Requires Improvement overall. (Previous inspection July 2017 – Requires Improvement)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Requires improvement
Are services well-led? – Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People Requires Improvement
People with long-term conditions – Requires Improvement
Families, children and young people – Requires Improvement
Working age people (including those recently retired and students – Requires Improvement
People whose circumstances may make them vulnerable – Requires Improvement
People experiencing poor mental health (including people with dementia) – Requires Improvement
This inspection was a comprehensive follow up inspection of Mayfield Medical Centre on 1 February 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 in July 2017.
We have previously carried out an announced comprehensive inspection at Mayfield Medical Centre on 5 September 2016. The overall rating for the practice was requires improvement. We completed a focused inspection on 6 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations 12 (safe care and treatment) and 17 (good governance) The practice had made some improvements but for others were unable to demonstrate how they met the regulations. The provider had a repeat breach to regulation 17 and we undertook enforcement action in the form of a warning notice. The provider was given a timescale of 31 October 2017 to become compliant with the warning notice. We completed a warning notice follow up inspection on 21 November 2017 and found that the practice was compliant with the warning notice.
The full reports from all of these inspections can be found by selecting the ‘all reports’ link for Mayfield Medical Centre on our website at www.cqc.org.uk
Overall the practice remains rated as requires improvement.
Our key findings were as follows:
- Improvements had been made to systems and processes around monitoring health and safety risk assessments. All actions from identified from a fire risk assessment had been completed. The practice had completed a further health and safety risk assessment and actioned any risks identified from this.
- All staff had received training suitable for their role including, fire safety, safeguarding and infection control.
- Improvements had been made to infection control policies which had been reviewed and embedded into practice. This included, all staff having received training and audits being completed in line with timescales set out in the practice policy.
- The practice demonstrated how they learned from significant events and complaints.
- The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines. However, there was no formal system in place to record that all staff had received or read the relevant guidance.
- Staff treated patients with kindness and respect. The practice had identified ways to enhance patient privacy in the waiting area.
- Approximately 30% of the practices population were either Nepalese or had Nepali heritage. As such the practice offered a range of clinics and assessments in Nepalese. This included the local Desmond group for diabetic care and memory assessments.
- Mayfield Medical Centre hosted a weekly youth counselling service to improve access to these services for young people in the local area.
- Policies had been reviewed and documented with version control measures.
- Patient satisfaction, as obtained from the national GP patient survey data, had declined since the previous inspection. This included for access to the service. There was no action plan in place to address this.
- Quality and Outcome Framework data was comparable to or below local and national averages. Although exception reporting levels for mental health indicators had improved since the previous inspection.
However, there were also areas of practice where the provider should make improvements.
The provider should:
- Review arrangements with external companies contracted to conduct specialist health and safety risk assessments so that documents are stored at the practice.
- Review the processes upon receipt of safety alerts before disseminating to all staff.
- Review the patient survey results to improve the patient experience at the practice.
- Review processes for increasing the outcomes for patients with long term conditions.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice