The Care Quality Commission
  • Doctor
  • GP practice

Mendlesham Medical Group

Overall: Good read more about inspection ratings

The Health Centre, Chapel Road, Mendlesham, Stowmarket, Suffolk, IP14 5SQ (01449) 767722

Provided and run by:
Mendlesham Medical Group

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Mendlesham Medical Group on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Mendlesham Medical Group, you can give feedback on this service.

04 May 2021

During an inspection looking at part of the service

We carried out an announced inspection at Mendlesham Medical Group on 4 May 2021. Overall, the practice is rated as good. The ratings for each key question are:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Following our previous report published April 2020 the practice was rated requires improvement overall and for providing safe and well led services. Effective services were inspected and rated good. The ratings for caring and responsive services were carried forward from the previous inspection and were rated good. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Mendlesham Medical Group on our website at www.cqc.org.uk

Why we carried out this inspection

Following our review of the information available to us, including information provided by the practice, we completed a comprehensive inspection. This was because there may have been a significant change to the quality of care provided since the last inspection. This inspection included a site visit to:

  • Inspect the key questions of safe, effective, caring, responsive and well led.
  • To follow up on breaches of regulation 12 and 17 and areas where the provider ‘should’ improve identified in our previous inspection

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:

  • 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
  • Conducting staff interviews using video conferencing and by telephone
  • Staff questionnaires
  • Requesting evidence from the provider and reviewing this
  • Requesting feedback from other stakeholders and patients who use the service
  • 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 and good for providing safe, effective, caring, responsive and well led services. All the population groups were rated as good except for people whose circumstances make them vulnerable, which we rated outstanding for responsive services. Due to our rating aggregation principles the population group people whose circumstances make them vulnerable is rated outstanding.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. Improvements had been made to the oversight arrangements for infection control and fire safety. Annual professional registration checks were completed and documented.
  • Improvements had been made to the oversight of the dispensary. Standard Operational Procedures (SOPs) had been written and updated for areas of practice identified at our previous inspection. These were mostly written in March 2021 and signed up to by all dispensary staff a few days before the inspection site visit. However, we saw evidence from practice documentation that correct processes had been followed prior to this.
  • Patients received effective care and treatment that met their needs. The practice were working to strengthen their monitoring arrangements for patients prescribed specific medicines.
  • 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. Patients could access care and treatment in a timely way.
  • There was a proactive approach to service delivery and partnership working with patients with a learning disability and their carers, to ensure their health needs were prioritised and met.
  • Due to COVID-19, the practice had appointed a domestic abuse advocate at the practice. They had completed additional training and had shared resources for support with all practice staff.
  • The practice had a written strategy and business plan which prioritised quality and sustainability. Systems and processes for governance had been strengthened and embedded and the registration of the provider was accurate and up to date.

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

  • Continue to embed the Standard Operating Procedures within the dispensary.
  • Continue to support the infection control lead nurse to undertake planned training which was postponed due to COVID-19.
  • Continue with plans to strengthen the monitoring arrangements for patients prescribed specific medicines.
  • Confirm in writing, information given to patients verbally in response to complaints raised.
  • Continue work to include an audit trail when policies were reviewed.

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

21/01/2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Mendlesham Medical Group on 21 January 2020. We decided to undertake an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection.

This inspection focused on the following key questions

  • are services safe
  • are services effective
  • are services well-led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • are services caring - good
  • are services responsive – good

At the last inspection on 19 October 2016 we rated the practice as good overall. The full comprehensive report (published July 2017) for this inspection can be found by selecting the ‘all reports’ link for Mendlesham Medical Group on our website at .

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 and for providing safe and well led services We have rated the practice as good for providing effective services and carried over our good rating for caring and responsive services. The practice is rated good for all the population groups.

We rated the practice as requires improvement for providing a safe and well led services because:

  • There was no process to ensure professional registration was maintained on an annual basis.
  • There was no documented evidence that identified risks from the fire risk assessment had been completed.
  • Infection prevention and control did not have leadership oversight.
  • Blank prescription pads were not being tracked as advised by guidance.
  • Standard Operating Procedures (SOP) did not contain detailed, written instructions to achieve uniformity of the performance of a specific function within the dispensary. For example, there was no SOP for the person who delivered medicines to patients homes and in-depth clarity regarding the difference between near miss and significant events.
  • The practice was unable to clearly demonstrate that the systems and processes in place to support the governance of the practice were well embedded, to maintain effective oversight of the service and to deliver service improvements.
  • Not all regulated activities were on their certificate.

We rated the practice as good for providing effective services and good for the population groups because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care they provided.
  • It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice understood the needs of its population and tailored services in response to those needs.
  • The practice had met the World Health Organisation (WHO) based national target of 95%.

The areas where the provider must make improvements are:

  • 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 areas where the provider should make improvements are:

  • Continue to develop, update and embed the standard operation procedures within the dispensary.
  • Continue to develop and embed a clear strategic vision to ensure quality and sustainability is prioritised. Develop a succession plan.
  • Develop a protocol for supporting and managing staff when their performance becomes poor or variable.
  • Improve the monitoring of blank prescription forms in line with national guidance.
  • Take necessary action to resolve the CQC registration issues.

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

13 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mendlesham Medical Group on 19 October 2016. The overall rating for the practice was ‘good’, with ‘requires improvement’ for providing safe services. The full comprehensive report on the 19 October 2016 inspection can be found by selecting the ‘all reports’ link for Mendlesham Medical Group on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 13 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 19 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system was in place for reporting and recording significant events. After our previous inspection the provider had implemented additional electronic recording procedures of significant events and other incidents. Learning from events was shared with the practice team and changes in practice were made in response to this.
  • We reviewed safety records, patient safety alerts and a new recording process which allowed the practice to share alerts with all staff. We saw evidence that these were shared with staff and action was taken.
  • The practice had implemented a system for checking medicine expiry dates in the dispensary.
  • Peripheral and clinical equipment available for use was stored safely and were within their expiry dates.
  • Complaints were handled appropriately and learning from these was shared with staff. An electronic system to record complaints had been implemented after our previous inspection.
  • A recruitment procedure was in place. The practice had undertaken recruitment since the last inspection and had applied interview processes that ensured a fair approach and questioning took place

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mendlesham Health Centre on 19 October 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • We found that generally there was an open and transparent approach to safety and a system was in place for reporting and recording significant events. However, this required improvement. Not all incidences had been recorded, learning from events was not shared effectively with the practice team, and the opportunities to take early interventions to encourage improvement were missed.
  • The practice used a range of assessments to manage the risks to patients.
  • Practice staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had been trained to provide them with the skills, knowledge, and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. The practice had scope to improve the system and process including documentation to ensure that improvements were made to the quality of care as a result of complaints and concerns.
  • Data from the national GP patient survey July 2016 showed that the practice performance was significantly higher than the national average. We received 85 comments cards, only two of these contained any negative feedback.
  • Patients said they found it easy to make an appointment with a named GP.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure that incidents that affect the health, safety, and welfare of people using the service are reported, reviewed, investigated, and monitored.

  • Ensure all dressings that are available for use are safely stored and within their expiry date.

The areas where the provider should make improvement are:

  • Review systems and process to ensure that complaints and feedback are managed effectively and safely. Minutes of meetings should contain sufficient detail to ensure shared learning by practice staff.

  • Review the practice policy for recruitment ensuring that it is followed and that all relevant documentation is recorded to ensure safe recruitment of practice staff.

  • The practice should review the recording of and retention of the documentation used to evidence the checks they have taken to ensure that medicines are within their expiry date.

  • Improve the recording of safety alerts to ensure sufficient detail to enable future monitoring.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice