We carried out an announced comprehensive inspection at Mallard Medical Practice on 8 November 2019.
At this inspection we followed up on breaches of regulations identified at a previous inspection on 7 November 2018 (last inspection rating: requires improvement).
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 rated the practice as requires improvement for providing safe services because:
- We were not assured that patients had been individually assessed to ensure it was medically appropriate for them to receive vaccines under a Patient Specific Direction (PSD).
- There was no system in place to ensure that patient safety alerts had been read an actioned.
- Systems which kept patients safe required improvement, such as the system for checking emergency medicines.
We rated the practice as good for providing effective, caring, responsive and well led services because:
- 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The practice had a culture which drove high quality sustainable care.
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Make changes to the system for disseminating safety alerts so that it is clear alerts have been read and actioned;
- Continue to ensure that all systems which have been put in place are clearly communicated to staff and are checked to ensure they are being followed correctly;
- Continue to work towards ensuring 80% of women eligible for cervical cancer screening at a given point in time are screened adequately.
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