2 November 2021
During a routine inspection
We carried out an announced inspection at Trinity Medical Centre on 2 November 2021. Overall, the practice is rated as Requires Improvement.
Safe - Requires Improvement
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led - Requires Improvement
Following our previous inspection on 11 June 2019 the practice was rated Requires Improvement overall and for the safe and effective key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Trinity Medical Centre on our website at www.cqc.org.uk
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.
Part of the inspection was carried out remotely with the intention of us spending 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.
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.
- Information from the provider, patients, the public and other organisations.
We have rated this practice as Requires Improvement overall and in the safe, effective, responsive and well-led key question.
We found that:
- Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the target of 90% in two areas where childhood immunisations are measured.
- Cervical cancer screening was below target for the percentage of women eligible for cervical cancer screening.
- The practice was above the CCG and England average for the prescribing of hypnotics and for the prescribing antimicrobial prescribing.
- Staff told us that staffing levels could be improved.
- Although staff confirmed that cleaning was completed daily, the cleaning checklist did not confirm which areas had been cleaned.
- We found instances when the provider had not carried out the appropriate monitoring of prescribed medication and patients with long-term conditions.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Leaders demonstrated that they understood the challenges to quality and sustainability and had identified the actions necessary to address these challenges.
We found breaches of regulations. The provider must:
- Ensure that care and treatment is provided in a safe way.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
- Introduce a cleaning schedule to confirm which areas of the practice have been cleaned.
- Discuss complaints during staff meetings to ensure all staff are informed and lessons are learned.
- Keep up to date with internal processes such as premises risk assessments.
- Continue to take steps to address staffing levels and telephone access for patients.
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