15 to 29 November 2022
During a routine inspection
We carried out an announced comprehensive inspection at King Edwards Medical Centre between 15 and 29 November 2022. Overall, the practice is rated as good.
Safe - good.
Effective – good.
Caring – good.
Responsive - requires improvement.
Well-led – good.
Following our previous inspection on 22 May 2017, 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 King Edwards Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this comprehensive inspection in line with our inspection priorities.
How we carried out the inspection/review
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.
- 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.
- Information from the provider, patients, the public and other organisations.
We found that:
- The practice had responded to the negative findings of the GP survey and patient’s complaints over the previous 12 months regarding long waiting times on the telephone and lack of appointments. However, at the time of this inspection the responses had only recently been implemented or were waiting commencement. We were therefore unable to establish if changes had made or would improve patient satisfaction in these areas.
- The leadership were responsive and immediately responded to the findings during the inspection to improve outcomes for patients.
- The practice had systems, practices and processes to keep people safe and safeguarded from abuse, which included close links with the local schools.
- There were adequate systems to assess, monitor and manage risks to patient safety.
- Patients received effective care and treatment that met their needs. The practice considered the needs of the practice population group.
- The practice had implemented a diabetes diet program in June 2020. One hundred and twenty patients had taken part to improve their diet and for weight management over two years. The program considered patients cultural needs, signposted patients for advice and invited family members to attend alongside the patient and allows access to a health wellbeing coach. Patients had improved outcomes, for example, three patients were able to stop all medications completely.
- The practice was the COVID vaccination centre and primary care network lead for the area. It had carried out the vaccination programs for people who were homeless, people who lived in residential care, and for refugees who were staying in local hotels.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
We found a breach of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
- Review and improve failsafe systems for and the uptake of cervical screening.
- Take steps to have evidence available of the training of locum and pharmacy working in the practice.
- Continue to formalise the supervision of clinical staff.
- Continue to ensure the effectiveness of the system to manage safety alerts.
- Continue to improve the system of annual review of patients with long-term health conditions.
- Continue to improve the effectiveness of the monitoring of high-risk medicines.
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