We carried out an announced inspection at Maypole Health Centre - Dr Michael on 2 June 2021. Overall, the practice is rated as good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring – Good (carried over from previous inspection)
Responsive – Good (carried over from previous inspection)
Well-led – Good
Following our previous inspection on 11 September 2019 the practice was rated as good for providing effective, caring and responsive services. However, it was rated as requires improvement for providing safe and well-led services and therefore, rated requires improvement overall.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Maypole Health Centre - Dr Michael on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up inspection to follow up on:
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Safe, effective and well-led
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The breaches previously identified
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We carried forward ratings for caring and responsive from previous inspections as the information we held did not indicate any change to ratings.
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
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 and good for all population groups.
We found that:
- The practice had acted on findings from our previous inspection in September 2019 and had made improvements.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Two senior GP partners and the practice manager had left the service since our last inspection. The practice had put in a new management structure and had improved its governance and culture. 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:
- Where patients are managed by secondary care, implement appropriate documentation to evidence that up to date blood test results were checked before prescribing medicine.
- Develop effective processes to ensure safeguarding concerns are escalated appropriately.
- Improve Personalised Care Adjustment (PCA) rates for patients with long term conditions such as diabetes and atrial fibrillation so that they are within local and national averages.
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