The Care Quality Commission
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  • GP practice

Archived: Sandringham Medical Centre

Overall: Requires improvement read more about inspection ratings

1a Aigburth Road, Aigburth, Liverpool, Merseyside, L17 4JP (0151) 727 1382

Provided and run by:
Sandringham Medical Centre

Important: The provider of this service changed. See new profile

All Inspections

7, 19 July and 4 August 2022

During a routine inspection

We carried out an announced inspection at Sandringham Medical Centre on 7, 19 July and 4 August 2022. Overall, the practice is rated as requires improvement.

Safe - Good

Effective - Good

Caring - Requires improvement

Responsive - Requires improvement

Well-led – Requires improvement

Following our previous inspection on 2 March 2020, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to review emerging risk.

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 requires improvement overall

We found that:

  • Satisfaction with care and treatment at the practice had declined in the last two GP patient surveys and the provider had not acted to rectify this.
  • Patient satisfaction with access to the practice by telephone and to obtain an appointment was lower than other local services.
  • There was not a consistent approach to the management of complaints and findings were not always used to improve the quality of care.
  • The systems and processes for identifying, managing and mitigating risk was not effective.
  • Oversight of the practice governance systems took place off site and did not always include local practice staff. Written procedures were not in place to support such arrangements.
  • Policies and procedures were not specific to the practice and related to other GP practices.

However:

  • 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We found two breaches of regulations. The provider must:

  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Continue to improve the uptake of cervical screening and immunisations.
  • Continue to review patients prescribed gabapentinoids.
  • Continue plans to reinstate the patient participation group and act on patient feedback.
  • Continue to identify carers and signpost to other agencies for support and guidance.

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

2 March 2020

During an inspection looking at part of the service

We carried out a comprehensive inspection of Sandringham Medical Centre on 8 March 2019. We rated the practice Good overall but Requires Improvement for providing safe services because there was a breach of regulations. The breach was:

Regulation 19: Fit and proper persons employed. Recruitment files for locum GPs did not contain the necessary up to date information required in schedule 3 of the regulation. In addition, there were no identification checks carried out by the practice when new GPs started work at the practice.

We also recommended that the practice should:

  • Update the locum induction information to include where emergency equipment and medicines are kept.
  • Increase the number of carers identified by the practice to help support them.
  • Update the practice website.
  • Ensure there is a separate area away from the reception desk for staff to answer telephone calls, so that reception staff can concentrate on meeting the needs of patients at the reception desk.
  • Continue to evaluate the appointment and telephone system to ensure changes introduced meet patients’ needs.
  • Ensure all nursing staff receive level three safeguarding training.

At this desk based follow up inspection 2 March 2020, we found that the provider had satisfactorily addressed these areas and therefore the practice is now rated as good for providing safe services.

We based our judgement of the quality of care at this service on a combination of:

• information from our ongoing monitoring of data about services and

• information from the provider, patients, the public and other organisations.

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

8 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Sandringham Medical Centre on 8 March 2019 as part of our inspection programme.

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, requires improvement for providing safe services and good for all population groups.

The practice is rated as requires improvement for providing safe services because:

Although there were some systems to ensure the safe care and treatment of patients, recruitment systems for GP locums required improvement. We found that not all the necessary up to date recruitment documentation required such as, revalidation information, indemnity certificates and identification was available. We also found that identification checks for locum GPs starting work at the practice were not always taking place.

The practice is rated 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. We were informed that the practice had identified that patients were not satisfied with the appointment system and a new triage system had recently been introduced with further plans to improve the telephone system.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The provider must:

  • Ensure specified information is available regarding each person employed.

The provider should:

  • Ensure all nursing staff receive level three safeguarding training.
  • Update the locum induction information to include where emergency equipment and medicines are kept.
  • Increase the number of carers identified by the practice to help support them.
  • Update the practice website.
  • Ensure there is a separate area away from the reception desk for staff to answer telephone calls, so that reception staff can concentrate on meeting the needs of patients at the reception desk.
  • Continue to evaluate the appointment and telephone system to ensure changes introduced meet patients’ needs.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

11 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sandringham Medical Centre on 11 February 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • The practice was clean and tidy and had good facilities including disabled access, car parking and access to translation services.

  • There were systems in place to mitigate safety risks including analysing significant events and safeguarding.

  • Patients’ needs were assessed and care was planned and delivered in line with current legislation.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service; including carrying out surveys and having a patient participation group (PPG) and acted, where possible, on feedback.

  • Staff worked well together as a team and all felt supported to carry out their roles. The practice encouraged training and staff were supported to further their careers.

There was an element of outstanding practice:

  • Patients had an option of using an automated telephone booking service from midnight on the same day to avoid having to call at 8am to get an appointment.

However, the areas where the provider should make improvements are:

  • Have a monitoring system in place for any blank prescriptions still in stock.

  • Update documented risk assessments in place for Control of Substances Hazardous to Health (COSHH).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice