We carried out an announced comprehensive inspection at Millstream Medical Centre on 07 December 2022. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 20 February 2019, 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 Millstream Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection as this was the first inspection under the new provider registration. This inspection covered all five domains – safe, effective, caring, responsive and well-led.
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.
- A short site visit.
- Obtaining information and feedback by external stakeholders
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:
- 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.
- Patients could access care and treatment in a timely way.
- The practice engaged with patients and the local community to obtain feedback to support service delivery and meet patient needs.
- Data was above national averages for patient satisfaction from the most recent GP national patient survey.
- 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:
- Continue to work with other services in the shared building to improve risk mitigation for fire safety, namely dedicated warden training and increased evacuation drills.
- Improve the uptake of cervical cancer screening and childhood immunisation to eligible patients.
- Implement the planned system to catch up with the backlog of records summarising.
- Take action to uphold oversight of required Controlled Substances Hazardous to Health (COSSH) data sheets in relation to all cleaning products stored at the practice.
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