We carried out an announced inspection at Sai Medical Centre on 27 June 2022. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
This location was previously registered under a different provider. We inspected the practice under the previous provider registration on 11 October 2016:
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Sai Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive to:
- Inspect and rate all key questions
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
- Requesting staff complete questionnaires
- Requesting the practice signpost patient to our website to complete ‘Give Feedback on Care’ forms for this service.
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
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, not all key staff were aware of how to access the safeguarding register.
- There was a system for recording staff immunisation status, however this was incomplete for some staff.
- Patient records did not always demonstrate that appropriate monitoring tests had been completed and reviewed prior to medicine being prescribed.
- There was a system in place for safety alerts, however tasks were not delegated when the lead for this area was busy with other work.
- Patients received effective care and treatment that met their needs.
- The practice had met the minimum targets for all childhood immunisations, aside from the combined measles, mumps and rubella immunisation aged five. The uptake for cervical screening was also below the required target.
- Feedback from patients was positive about how staff treated them 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 practice used patient feedback to monitor this.
- There were systems for risk identification, investigating significant events and complaints. In some instances, opportunities to review and strengthen governance systems related to these were missed.
- 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:
- Improve safeguarding processes so that all relevant members of staff are aware of how to access the safeguarding register.
- Improve processes relating recording of staff immunisation status.
- Strengthen the processes for recording results taken from the hospital pathology system.
- Continue to develop processes relating to significant events, specifically relating to monitoring progress on any outcomes or actions and making sure all significant events raised are logged.
- Improve the protocol for dealing with safety alerts so that actions are dealt with in a timely manner.
- Continue to improve awareness and uptake of the combined measles, mumps and rubella immunisation aged five and cervical screening uptake.
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