Mundesley Medical Centre

We decided to undertake an inspection of this service on 1 October 2019 following our annual review of the information available to us. This inspection was to follow up on the breach of regulation identified at our previous inspection in December 2018 and we looked at the safe key question only.

Our judgement of the quality of care at this service is based 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.

This means that:

• The service had completed a fire risk assessment and had completed actions identified.
• The service had completed infection prevention and control audits regularly to continually assess and improve their service.
• Patient Group Directions were authorised and there was a system in place to monitor expiry dates.
• Blank prescription stationery was monitored and stored appropriately.
• Staff had signed Standard Operating Procedures and these were reviewed regularly.
• Patient safety alerts had been actioned, although the oversight of the system was unclear.

The area where the practice should make improvements:

• Review and improve the oversight of the safety alert system to enable all staff to be clear on their roles and responsibilities.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BS BM BMedSci MRCGP
Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mundesley Medical Centre on 11 December 2018 as part of our inspection programme. The practice was previously inspected in April 2016 and rated as good.

Our inspection team was led by a CQC inspector and included a GP specialist advisor and a second CQC inspector.

Our judgement of the quality of care at this service is based 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.

This means that:

• People were protected from avoidable harm and abuse and that legal requirements were met.
• The provider had a detailed action plan in place to address shortfalls within the practice, such as upskilling staff to address issues with recruiting GPs.
• Patients had good outcomes because they received effective care and treatment that met their needs.
• The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and drive care. For example, the practice had an effective system to monitor patients on a range of medicines, including high risk medicines. This included monthly searches and recalls for patients due a blood test.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• People’s needs were met by the way in which services were organised and delivered. For example, the practice had introduced a new appointment system to ensure patients were seen by the appropriate clinician.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
• The practice encouraged continuous improvement and innovation. For example, they were supporting a nurse to gain a prescribing qualification including study time and mentorship.
• Many staff had won awards for the care they provided and the work that had been completed. This included awards for a GP, nurse and administration staff.
• Staff reported they were happy to work in the practice and proud of the changes that had been made.

We rated the practice as requires improvement for providing safe services because:

• The practice had not completed a fire risk assessment since November 2015. After the inspection, the practice sent us an updated fire risk assessment.
• The practice had not completed a full infection prevention and control audit. After the inspection, the provider informed us they would allocate time every month for further audits to be completed.
• Staff logged prescription stationary and they were stored securely, however they did not monitor their use. After the inspection, the practice informed us they had contacted the Clinical Commissioning Group to ask for advice on how to appropriately monitor prescription pads.
• Patient Group Directions (PGDs) had not been authorised. The practice acted on this immediately and signed them on the day of inspection.
• Staff were knowledgeable about the dispensing processes, however not all staff had signed the Standard Operating Procedures.
• The practice did not have full oversight of all safety alerts, however the alerts we checked had been actioned. On the day of inspection, the practice set up a log to monitor alerts and actions taken.

We found the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found the provider should:

• Review Standard Operating Procedures to ensure staff have read and signed these.
• Embed the new system for monitoring patient safety alerts.
• Review and improve the system for the logging of prescription stationary to ensure this is in line with recognised guidance.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice