• Doctor
  • GP practice

Mandalay Medical Centre

Overall: Good read more about inspection ratings

933 Blackburn Road, Bolton, Lancashire, BL1 7LR 0844 477 1751

Provided and run by:
Mandalay Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Mandalay Medical Centre 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 Mandalay Medical Centre, you can give feedback on this service.

21 December 2019

During an annual regulatory review

We reviewed the information available to us about Mandalay Medical Centre on 21 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

21/12/2017

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 Mandalay Medical Centre on 4 November 2016. The overall rating for the practice was good, with a rating of requires improvement in the safe domain. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Mandalay Medical Centre on our website at www.cqc.org.uk.

We then carried out an announced focused inspection 10 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 November 2016. In this inspection we found that some improvements had been made but we identified areas that needed further improvement. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for Mandalay Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk based review to confirm the practice had made the required improvements from the previous inspection.

Overall the practice is now rated as good in all domains.

Our key findings were as follows:

  • Legionella checks were carried out on water outlets set out in the legionella risk assessment. The practice had taken action to ensure themselves that the temperatures recorded were acceptable.

  • Fire drills were now being carried out by the practice and documented. All staff had received fire safety awareness training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10/08/2017

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 Mandalay Medical Centre Health Centre on 4 November 2016. The overall rating for the practice was good, with a rating of requires improvement in the safe domain. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Mandalay Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 November 2016. This report covers our findings in relation to those requirements.

Overall the practice is rated as good. The rating for the safe domain remains requires improvement.

Our key findings were as follows:

  • There was a robust recruitment process and all required information for staff was held.

  • Staff had been informed of the procedure to follow when chaperoning patients.

  • Staff had an appraisal within the last 12 months.

  • A health and safety and fire safety risk assessment had been carried out and all required checks were regularly performed.

  • Arrangements were ongoing for staff to receive face to face fire safety training.

  • No fire drill had ever taken place at the practice.

  • Although regular legionella checks were carried out these were not for all required water outlets and advice or action had not been taken when water was below the minimum safe temperature.

The area of practice where the provider needs to make improvements is:

  • The provider must ensure care and treatment is provided in a safe way to patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

04/11/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mandalay Medical Centre on 4 November 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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:

  • The provider must ensure all the required information is available for new employees prior to them starting work.

  • The provider must assess the risks to the health and safety of patients by having a health and safety risk assessment, fire risk assessment and legionella risk assessment.

  • The provider must ensure all medical devices are within their expiry dates and disposable privacy curtains are changed at the correct frequency.

In addition the provider should:

  • Ensure all staff are aware of the procedure to follow when chaperoning.

  • Continue with their plans to bring appraisals up to date for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice