Archived: Princes Medical Centre

We carried out an announced inspection at Princes Medical Centre on 9 December 2021 (paused due to pandemic), 11 and 18 February 2022. Overall, the practice is rated as requires improvement.

The ratings for the key questions are as follows:
Safe - Requires Improvement
Effective – Requires Improvement
Caring - Good
Responsive - Requires Improvement
Well-led – Requires Improvement

The practice has not been inspected under their current registration with CQC. However, the service was inspected under a previous registration on 18 May 2017. At the inspection in May 2017 the practice was rated Good overall and
for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for J Musil & Partner on our website at www.cqc.org.uk.

Why we carried out this inspection:

This inspection was a comprehensive inspection of Princes Medical Centre as a new registration.

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 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
• 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 Requires Improvement overall

We found that:

• the practice did not always provide care in a way that kept patients safe;
• the practice did not have assurance on issues identified from risk assessments, audits or safety alerts;
• the practice did not have assurance of sustainability and stable clinical workforce;
• patients ongoing needs were not always fully assessed and delivered in line with current guidance;
• patient’s treatment was not always regularly reviewed and updated;
• the practice had a programme of quality improvement activity but there was scope to strengthen this further to improve the outcomes of care and treatment;
• 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. Continuity of care for patients was an issue with only one salaried GP;
• there was a lack of governance, leadership, capacity and oversight in areas of the practice such as clinical oversight;
• the practice had not always identified risks or had assurance that actions had been completed; and
• Silo working in and between teams led to gaps.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

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

The provider should:

• Review the staffing levels allocated to the practice
• Continue to monitor and take actions to improve the uptake for childhood immunisations and cervical cancer screening for women at the practice.
• Continue to monitor and take action to address backlogs to patient reviews.
• Continue to explore ways of establishing a Patient Participation Group.
• Continue to explore ways of improving communication barriers and making information more accessible.

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