Somerset Medical Centre, Grand Union Village Health Centre

We carried out an announced comprehensive inspection at Somerset Medical Centre, Grand Union Village Health Centre on 6 July 2022. Overall, the practice is rated as good.

Safe - requires improvement

Effective – good

Caring - good

Responsive - good

Well-led - good

Why we carried out this inspection

This was the provider’s first inspection following its registration with CQC on 21 April 2020. This was a comprehensive inspection, covering all five of the key questions we usually look at during an inspection; safe, effective, caring, responsive and well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, we did find instances where some patients prescribed hig-risk drugs were not monitored or reviewed accordingly.
• Patients did not always receive effective care and treatment that met their needs. Some patients diagnosed with a long-term condition were not monitored and reviewed accordingly.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• 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.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients

Whilst these were not breaches of regulations, the provider should:

• Maintain records of up to date risk assessments carried out by the landlord.
• Improve uptake of cervical smears and childhood immunisations.
• Implement a protocol to clarify appropriate tasks for Healthcare Assistants (HCAs) to undertake.
• Implement a review to ensure all patients with Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions are identified and recorded appropriately.
• Prepare and Implement a clear action plan to address concerns raised through the GP patient survey and improve the recording and review of complaints.

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