Prince of Wales Medical Centre

We carried out an announced inspection at Prince of Wales Medical Centre on 16 May 2022. Overall, the practice is rated as Inadequate.

The ratings for each key question are as follows:

Safe – Inadequate

Effective – Requires improvement

Caring: Good

Responsive: Good

Well-led - Inadequate

At the previous inspection on 2 June 2016, we rated the practice as Good overall (Good for key questions Safe, Effective, Caring, Responsive, Well Led).

Due to unavoidable operational circumstances at CQC this report has been delayed. However, the major issues were raised with the practice at the time of inspection.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Prince Of Wales 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. As part of the inspection there was a remote review of clinical records on 9 and 11 May 2022, prior to the site visit. This was a comprehensive inspection looking at the five key questions of safe, effective, caring, responsive, and well-led.

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 and staff returning completed CQC staff feedback form.
• 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 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.
• Information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall.

We found that overall governance arrangements within the practice were ineffective which resulted in potential risks to patients. The practice was not consistently following its own policies and procedures:

• Our clinical searches found that the practice had not taken enough action to assess and manage risks to the patients, arising from MHRA safety alerts. However the quality of clinical care provided to patients, including those with long term conditions was of a good standard.
• There were gaps in systems to assess and manage health and safety risks, including ineffective policies and procedures, and absence of necessary assessments of risks including health and safety risk assessment.
• There were shortfalls in the management of medicines, specifically the management of emergency medicines and vaccine storage and handling.
• There were gaps in the fire safety processes including, absence of fire risk assessment, up to date staff training and regular fire drills.
• The governance arrangements for keeping proper records needed improvement.
• There was no evidence of a formalised and auditable process for clinical supervision, coaching and peer review for clinicians.
• The practice was not ensuring all staff training was up to date.
• Recording the detail of patient complaints and sharing of learning across staff needed to be improved.

We found breaches of regulations. The areas where the provider must make improvements are:

• 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:

• Continue to implement a programme to improve uptake for cervical screening and childhood immunisations.
• Review recruitment check procedures to ensure risk assessments are carried out for the re-employment of any staff.
• Make easy read materials available and patient information available in other languages and formats.
• Review the quality of the notes circulated following safeguarding meetings to prevent any misunderstanding of actions and decisions agreed.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services