- GP practice
Archived: Gladstone Medical Centre
All Inspections
20 November 2019
During a routine inspection
We carried out an announced comprehensive inspection at Gladstone Medical Centre on 20 November 2019 as part of our inspection programme.
At this inspection, we followed up on breaches of regulations identified at a previous inspection on 3 October 2018. Previous reports on this practice can be found on our website at: https://www.cqc.org.uk/location/1-646669600.
At this inspection, we found that the practice had demonstrated improvements in most areas.
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, with the exception of working age people (including those recently retired and students) which is rated as requires improvement.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
- The practice’s uptake of the national screening programme for cervical, breast and bowel cancer screening and childhood immunisations rates were below the national averages.
- The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms for use in printers were recorded correctly, and records were maintained as intended in line with national guidance.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Feedback from most patients reflected that they were able to access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
- Staff had the skills, knowledge and experience to deliver effective care and treatment.
- Information about services and how to complain was available.
- The practice was aware of and complied with the requirements of the Duty of Candour.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
We rated all population groups as good for providing responsive services. We rated all population groups as good for providing effective services, with the exception of working age people (including those recently retired and students) which are rated as requires improvement, because of low cervical screening rates.
Whilst we found no breaches of regulations, the provider should:
- Continue to encourage and monitor the childhood immunisation, cervical, breast and bowel cancer screening uptake.
- Promote the awareness of the documented fire evacuation plan.
- Review the governance arrangements to ensure effective monitoring of blank prescription forms in line with national guidance.
- Continue to review and monitor the exception reporting for diabetes related indicators.
- Consider to carry out formal analysis of internal surveys carried out by the practice and develop an action plan if required.
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
3 October 2018
During a routine inspection
This practice is rated as requires improvement overall.
(At the previous inspection in February 2015 the practice was rated as good overall but the safe domain was rated as requires improvement).
The key questions are rated as:
Are services safe? - Requires improvement
Are services effective? - Requires improvement
Are services caring? - Good
Are services responsive? - Requires improvement
Are services well-led? - Good
We carried out an announced comprehensive inspection at Gladstone Medical Centre on 3 October 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Gladstone Medical Centre was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
At this inspection we found:
- Risks to patients were assessed and well managed in some areas, with the exception of those relating to the level of exception reporting and management of blank prescription forms.
- The practice’s uptake of the national screening programme for breast and bowel cancer screening and childhood immunisations rates were below the national averages.
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Some staff had not received all the required training that was relevant to their role.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Results from the August 2018 annual national GP patient survey showed that patients’ satisfaction with how they could access care and treatment was significantly below the local and national averages.
- The practice was aware of and complied with the requirements of the Duty of Candour.
- 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 areas where the provider must make improvements as they are in breach of regulations are:
- 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:
- Review and ensure all staff have received training relevant to their role including sepsis awareness training.
- Implement a system to ensure the record keeping of a defibrillator checks.
- Review staff feedback in relation to non-clinical staffing levels.
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Continue to promote the benefits of the national screening programme and monitor the practice’s uptake for breast and bowel cancer screening.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
12 March 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Gladstone Medical Centre on 12 March 2015. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for five out of the six population groups we report on. It required improvement for providing safe services and for providing care to people whose circumstances may make them vulnerable.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance.
- 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 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.
However there were areas of practice where the provider needs to make improvements.
Importantly the provider must:
- Improve the storage arrangements for vaccines and other medicines to ensure these comply with best practice guidelines.
- Carry out an infection control audit to monitor for any risks to staff or patient safety.
In addition the provider should:
- Review staff knowledge of the Deprivation of Liberty Safeguards (DoLS) legislation as it applies to general practice because it may be relevant to work carried out at a local care home.
- Review and update the business continuity plan to ensure that adequate emergency arrangements are in place.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice