Archived: Sandringham Medical Centre

Updated 9 September 2022

Sandringham Medical Centre is located in Liverpool at:

1A Aigburth Road

Aigburth

Liverpool

Merseyside

L17 4JP

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.

The practice is situated within the Liverpool Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 6265. This is part of a contract held with NHS England.

The practice is part of a Liverpool First Primary Care Network, a wider network of GP practices.

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is, 86.2% White, 4.4% Mixed, 3.5% Asian, 3.4% Black, and 2.6% Other.

The age distribution of the practice population closely mirrors the local and national averages. There are more working age patients registered at the practice.

The service is led by two GP partners. The GPs are supported at the practice by a practice nurse and team of reception/administration staff. The practice manager and assistant practice manager provide managerial oversight. Additional clinical staff from one of the partners other GP practices and agency support the practice. These roles include GP’s, Advanced nurse practitioners (ANP) clinical pharmacists and mental health practitioners.

The practice is open between 8am to 6.30pm Monday to Friday. The practice provides a triage telephone appointment system.

Out of hours services are provided by Primary Care 24.

Updated 9 September 2022

We carried out an announced inspection at Sandringham Medical Centre on 7, 19 July and 4 August 2022. Overall, the practice is rated as requires improvement.

Safe - Good

Effective - Good

Caring - Requires improvement

Responsive - Requires improvement

Well-led – Requires improvement

Following our previous inspection on 2 March 2020, 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 Sandringham Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to review emerging risk.

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 requires improvement overall

We found that:

• Satisfaction with care and treatment at the practice had declined in the last two GP patient surveys and the provider had not acted to rectify this.
• Patient satisfaction with access to the practice by telephone and to obtain an appointment was lower than other local services.
• There was not a consistent approach to the management of complaints and findings were not always used to improve the quality of care.
• The systems and processes for identifying, managing and mitigating risk was not effective.
• Oversight of the practice governance systems took place off site and did not always include local practice staff. Written procedures were not in place to support such arrangements.
• Policies and procedures were not specific to the practice and related to other GP practices.

However:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We found two breaches of regulations. The provider must:

• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Continue to improve the uptake of cervical screening and immunisations.
• Continue to review patients prescribed gabapentinoids.
• Continue plans to reinstate the patient participation group and act on patient feedback.
• Continue to identify carers and signpost to other agencies for support and guidance.

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