Cassidy Medical Centre

We carried out an announced inspection at Cassidy Medical Centre on 6 July 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Requires improvement

Well-led - Good

Following our previous inspection on 20 February 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 Cassidy Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection due to specific concerns relating to the parent provider. There were no specific concerns relating directly to Cassidy Medical Centre. We inspected and rated three key questions:

• Safe
• Effective
• Well-Led.

We inspected the Responsive key question and this was not rated.

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 short 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 found that:

• Patients with long term conditions and/or taking high risk medicines were not always monitored appropriately or in a timely manner. We saw evidence that overdue reviews had been completed only following the announcement of the inspection.
• Rates of cervical and cancer screening, and childhood immunisations were below the expected level although these rates are comparable with other practices in the local area. We saw proof that the practice had been engaging in two-cycle audits that were ongoing in order to improve figures. The impact of this has not yet been seen however rates of bowel and breast cancer screening and childhood immunisations had been steadily increasing since 2018.
• There were clear and effective systems in place to keep people safe and manage risk.
• The practice was proactive in undertaking quality improvement measures across the service including audit, engagement and patient education.
• There was adequate quality assurance and improvement measures in place.
• We saw evidence of open and inclusive culture where staff were valued and demonstrated good levels of teamwork for the benefit of the patients.
• There were appropriate policies and procedures in place to ensure staff and patients were safe and well cared for.
• There were regular practice meetings to discuss learning, significant events, improvements and communicate any changes.

Whilst we found no breaches of regulations, the provider should:

• Monitor systems’ efficacy to ensure timely and adequate monitoring and reviews of patients on high risk medicine and/or with long term conditions.
• Provide adequate support, supervision and lines of communication for junior staff and new/trainee clinicians.

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