Archived: Trentham Mews Medical Centre

We carried out an announced, comprehensive inspection at Trentham Mews Medical Centre on 17 February 2020 to follow up on previous breaches of regulation.

We had previously carried out an announced, comprehensive inspection of Trentham Mews Medical Centre on 16 November 2018 and rated the practice as requires improvement overall and in safe and well-led. We rated effective, caring and responsive as good. We issued requirement notices for safe care and treatment and fit and proper persons employed. We also made four best practice recommendations:

• Update policies to ensure they reflect current guidance.
• Provide reception staff with training to identify the rapidly deteriorating patient.
• Implement and monitor changes required as identified in the infection control audit.
• Improve government arrangements and risk management processes so that they operate effectively.

Trentham Mews Medical Centre changed its legal identity from a partnership provider to a single-handed GP practice in September 2019. The full comprehensive report for the inspection in November 2018 can be found by selecting the ‘all reports’ link for Trentham Mews Medical Centre on our website at www.cqc.org.uk.

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 in all key questions. We rated each population group as good except for vulnerable adults which we rated a s requires improvement.

We found that:

• The practice had systems, practices and processes to keep patients safe. However, systems to safeguarded children and vulnerable adults from abuse were not always effective.
• There was a system in place for reporting, investigating and sharing learning from significant events. However, an overall system for reviewing trends over time was not in place.
• Patients received effective care and treatment that met their needs.
• The practice had a comprehensive programme of quality improvement and used information about care and treatment to make improvements.
• Staff treated patients with kindness, respect and compassion and respected their privacy and dignity.
• Patient satisfaction with access to appointments was overwhelmingly positive.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• The issues identified in the requirement notices for safe care and treatment and fit and proper persons employed, issued at our previous inspection, had been appropriately addressed.
• The four best practice recommendations identified at our previous inspection had been appropriately addressed.

The areas where the provider should make improvements are:

• Follow up children that did not attend hospital appointments.
• Appropriately code vulnerable adults within the practice’s computer system.
• Update the practice leaflet to include contact details for the Public Health Service Ombudsman to support patients that wish to complain.
• Identify trends over time from significant events and complaints.

We found one area of outstanding practice:

• All four national GP survey indicators regarding access to appointments were above the local and national averages. Patient satisfaction with telephone access to the practice was 97% which was significantly above the national average of 68%.

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