Background to this inspection
Updated
17 November 2021
Montpelier Health Centre is located in Bristol at:
Bath Buildings
Bristol
Avon
BS6 5PT
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG) and delivers Personal Medical Services (PMS) to a patient population of about 26,200. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices and works collaboratively in two Primary Care Networks, Bristol and Inner City and Severnvale. The practice are part of the Health and Social Care system in Bristol which includes the BNSSG CCG, Bristol City Council, South Gloucestershire Council, secondary care providers and the voluntary and third sector. All members work together to implement a sustainability and transformation for joined up health and social care.
According to Public Health England data, 36% of the practice population is from non-white ethnic groups.
Information published by Public Health England, rates the level of deprivation within the practice population group as two, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The provider’s clinical team consists of five GP partners, 10 salaried GPs, a consulting clinical pharmacist, a clinical pharmacist, two nurse managers, eight practice nurses, four health care assistants, a district nurse, a paramedic, a physician’s associate, an urgent care practitioner and a minor illness nurse. The administration team consists of a practice manager, deputy practice manager, administration manager and reception and administration staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Out of hours services are provided by BrisDoc via the NHS 111 telephone number.
Updated
17 November 2021
We carried out an announced inspection at Montpelier Health Centre on 3 and 9 September 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective -Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 26 June 2019, the practice was rated Requires Improvement overall and for the key questions of providing effective services and well-led services. We identified a breach of the Regulation 17 (Good Governance) and issued a requirement notice. The practice needed to establish and operate effective quality assurance systems and processes to ensure compliance with the regulations.
In particular we found:
- There was not effective oversight of staff training. Not all staff were up to date or had received training in line with practice policy and national guidance.
- Systems to ensure policies were consistently followed, were not embedded.
- Practice systems for exception reporting did not ensure this was always appropriate and that patients received necessary care and treatment.
- Processes to mitigate risks to patients and staff were not embedded. For example, systems to monitor blank prescriptions stationery.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Montpelier Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection a comprehensive inspection, which included a site visit. The key questions inspected included:
- Is the service safe?
- Is the service effective?
- Is the service well-led?
We also checked if the practice met the compliance with the Regulation 17 (Good Governance).
Ratings from the caring and responsive key questions were carried from our inspection in June 2019, when these both key questions were rated as good.
How we carried out the inspection/review
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 and good for all population groups.
We found that:
- The requirement notice issued following our inspection in June 2019 had been met and governance systems were effective and ensured the health safety and welfare of patients.
- 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.
- 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.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Consider maintaining records for all cleaning activities carried out at the practice, in particular cleaning of clinical rooms between patient consultations.
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