We carried out an announced inspection at Clarendon Medical Centre on 2 November 2022. Overall, the practice is rated as good.
The key questions are rated as:
Safe – Requires improvement
Effective – Good
Caring – Good (rating awarded at the inspection November 2015)
Responsive – Good (rating awarded at the inspection November 2015)
Well-led – Good
The provider was last inspected November 2015 and was rated Good overall and in all the key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Clarendon Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this inspection as part of a selection of services rated good and outstanding who have not been inspected for five years or more.
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 by telephone and 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
- Gaining feedback from staff using staff questionnaires
- A shorter 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
We have rated this practice as good for providing effective and well-led services because:
- The practice in the main 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.
- 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.
Following this inspection, we have rated the practice requires improvement for providing safe services. Whilst we found no breaches of regulations, the provider should:
- Complete the infection prevention and control action plan and embed systems to ensure improvements are maintained.
- Ensure the new processes put in place for monitoring patients prescribed high risk medicines are embedded.
- Continue to monitor prescribing multiple psychotropics for patients is in line with guidance.
- Continue work to improve cervical screening uptake.
- Ensure the new processes put in place regarding safety alerts are maintained.
- Continue to monitor that Patient Group Directions (PGDs) are signed.
Following the inspection, the practice provided details of the actions they planned to take to improve. For example, they have developed a plan to address concerns raised in the key question safe, which included developing an overarching governance system to monitor patients prescribed high risk medicines and to ensure actions are taken following receipt of safety alerts. There was also an infection prevention and control action plan in place.
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