27 June & 3 August 2022
During an inspection looking at part of the service
We carried out an announced focused inspection at Southdene Medical Centre on 27 June and 3 August 2022. Due to some concerns we then changed the inspection to a comprehensive inspection. Overall, the practice is rated as Requires improvement.
Set out the ratings for each key question
Safe - Requires improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led – Requires improvement
At our previous inspection of 24 November 2016, the practice was rated outstanding overall and for the key questions of safe, effective and well-led. They were rated as good for the key questions of caring and effective.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Southdene Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection as part of our direct monitoring intelligence system Band 1 sampling exercise. This exercise is looking at a percentage of band 1 locations in each sector with published statements on our website as part of our quality assurance process to monitor the effectiveness of our new monitoring approach. We need assurance that Good or Outstanding rated locations are still good or outstanding and that we were right to publish the public statement.
How we carried out the inspection/review
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 questionnaires, phone calls and 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:
- Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses.
- Patients mostly 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 adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The shortage of established GPs had an impact on the practice not being able to keep up to date with care plans, medication reviews and the reviewing of prescribing.
We found a breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients. (See Requirement Notice Section at the end of this report for further detail).
The areas where the provider should make improvements are:
- Implement a system to review historical patient safety alerts.
- Continue to review care plans for patients with poor mental health.
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