24 August 2022
During a routine inspection
We carried out an announced comprehensive at The Margaret Thompson Medical Centre on 17 and 24 August 2022. Overall, the practice is rated as requires improvement.
The key questions are rated as:
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive - good
Well-led - requires improvement
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Margaret Thompson Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- 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 requires improvement overall.
We have rated this practice requires improvement for providing safe services. This is because:
The practice is rated as requires improvement for providing safe services. This is because:
- There was limited use of systems to record and report safety concerns, incidents and near misses. Some staff were not clear how to do this.
- The provider did not have oversight of all referrals to secondary care.
- Historical safety alerts were not always reviewed to ensure actions were followed.
We have rated this practice requires improvement for providing effective services. This is because:
- Not all staff had undertaken the relevant training updates to do their job. The learning needs of staff were not fully understood.
- There were gaps in management and support arrangements for staff as appraisal, supervision and professional development was not routinely offered.
We have rated this practice good for providing caring services. This is because:
- The provider supported patients with kindness, dignity and respect.
We have rated this practice good for providing responsive services. This is because:
- Patients were able to access care and treatment within an appropriate timescale for their needs.
We have rated this practice requires improvement for providing well led services. This is because:
- Leaders were not always aware of the risks, issues and challenges in the practice.
- There has been no recent review of the governance arrangements, the strategy, or plans.
- There was a lack of effective governance systems for managing risk, issues and performance.
We found two breaches of regulations. The provider must:
- Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards of care and treatment.
- 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 with the replacement schedule for clinic room flooring and chairs.
- Review and improve the uptake of cervical cancer screening and childhood immunisations.
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