Victoria Medical Centre

We carried out an announced comprehensive inspection at Victoria Medical Centre on 12 and 21 December 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective -requires improvement

Caring - good

Responsive -requires improvement

Well-led - requires improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Victoria Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We inspected the practice because it was newly registered following the merging of three practices. This inspection was comprehensive and covered the safe, effective, caring, responsive and well-led key questions.

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.
• Short visits to the main surgery and the branch.

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:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had an active patient participation group and patient views were acted on to improve services and culture.
• The practice prioritised training and supported staff to obtain additional skills and qualifications.
• The facilities were modern, and purpose built, and the environment was clean and hygienic.
• The practice had implemented new systems and recruited additional staff to help improve patient access.

We rated the practice as requires improvement for providing safe services because:

• Policies and procedures for keeping children and vulnerable adults safeguarded from abuse were not always clear or operating effectively.
• The practice did not have an effective policy and procedure for reporting and recording significant events. There was limited evidence to show that events had been acted on and the learning identified and shared.
• The system for recording and acting on safety alerts was not always effective.
• Blank prescriptions were not always kept securely, and their use monitored in line with national guidance.
• The practice was unable to demonstrate that emergency medicines were properly stored and immediately accessible.
• There was limited evidence of effective reviews to ensure the medicines a patient was taking were still appropriate.
• The practice had not monitored the prescribing of controlled drugs in line with national guidance.
• The practice did not have a system for ensuring medical oxygen and defibrillators were regularly checked and fit for use.
• Vaccines were not always appropriately stored and monitored in line with UK Health Security Agency (UKHSA) guidance to ensure they remained safe and effective.

We rated the practice as requires improvement for providing effective services because:

• Not all patients with a long-term condition or a potential missed diagnosis had received appropriate monitoring and clinical review.

We rated the practice as requires improvement for providing responsive services because:

• Complaints were not always responded to appropriately or used to improve the quality of care.

We rated the practice as requires improvement for providing well-led services because:

• Leaders lacked oversight of some processes and therefore failed to identify risks when those processes did not operate as intended.
• The practice did not always act on appropriate and accurate information.

We found two breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Continue with ongoing work to ensure staff vaccination is maintained in line with current UKHSA guidance.
• Improve the uptake for cervical screening to ensure at least 80% coverage in line with the national target.
• Improve the uptake of childhood immunisations to ensure the minimum 90% target is met.
• Ensure all staff are up to date with essential training.
• Ensure that clinical supervision for staff in advanced clinical roles is embedded.
• Continue to monitor and improve patient access to appointments.
• Update the practice website to include information about all clinical staff and local support groups.
• Ensure that staffing levels are enough to cover absence and busy periods and that staff can take regular breaks.

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