Background to this inspection
Updated
12 October 2022
The provider, Great Western Hospitals NHS Foundation Trust (hereafter referred to as The Trust), provides acute hospital services at the Great Western Hospital. On 28 November 2019, the Trust took over the running of Moredon Medical Centre which is located at:
Moredon Medical Centre
Moredon Road
Swindon
SN2 2JG
Moredon Medical Centre is based in Swindon, Wiltshire, and is one of 22 practices serving the NHS Swindon Clinical Commissioning Group (CCG) area. A staffed reception area is located on the ground floor, and the practice has consulting/treatment rooms on the ground and first floors. The practice provides services to around 12,130 registered patients. Moredon Medical Centre provides the following regulated activities:
- Treatment of disease, disorder or injury
- Diagnostic and screening procedures
- Maternity and midwifery services
- Surgical procedures
- Family planning
The Trust’s Chief Executive Officer is also the Registered Manager and Nominated Individual (the person responsible for supervising the management of the carrying on of the regulated activities). The management of the practice is overseen by the Trust’s Deputy Divisional Director of Community and Primary Care Services and run locally by the Head of Operations and Primary Care Network Manager. The management team also consists a primary care clinical lead and a primary care head of nursing.
The practice is part of a wider network of GP practices, the Trust also provides another GP practice within Swindon and together these practices have formed a Primary Care Network (PCN).
Information published by Public Health England shows that deprivation within the practice population group is in the fifth lowest decile (5 of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is, 91.0% White, 5.4% Asian 1.3% Black, 2.0% Mixed, and 0.3% Other.
There is a team of 9.2 full time equivalent GPs at the practice. The practice has a team of 8.9 full time equivalent nurses who provide nurse-led clinics for long-term condition. The GPs are supported at the practice by a team of reception/administration staff. The PCN operations manager and business support manager are based at this surgery but works between all the PCN surgeries.
Moredon Medical Centre is open Monday to Friday 8am to 6.30pm. They can also offer extended hour appointments from 7.30am to 8pm.
The practice offer a range of appointment types including book on the day, telephone consultations and advance appointments.
Outside of these times patients are directed to contact the out-of-hours service by using the NHS 111 Number.
Updated
12 October 2022
We carried out an announced inspection at Moredon Medical Practice on 9th September (remote) and 14th September 2022 (on-site) in response to issuing a warning notice 29a. This inspection was to assess compliance against the areas identified in the warning notice issued in May 2022 and as such was not rated. Therefore, the ratings from the previous inspection remain until we return to do a rated inspection.
Safe - Requires Improvement
Effective – Requires Improvement
Caring – Good
Responsive – Good
Well-led – Requires Improvement
Following our previous inspection on 6th to 9th May 2022, the practice was rated Requires Improvement overall and for all key questions except for effective, caring and responsive key questions which were rated as Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Moredon Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection.
Following the issuing of a warning notice 29a on 24th May 2022, we undertook this focussed inspection to gain assurance that the practice were now compliant with the areas they were in breach of regulation.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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:
- 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
In this inspection we found that:
- The practice had made improvements in all areas identified in the warning notice and were now compliant.
- Systems were in place to ensure consistent clinical coding and summarising.
- Keypads and key fobs had been utilised to ensure patients and visitors to the practice could not enter non-patient areas.
- A system of routine audit had been put into place to ensure appropriate coding of patients with pre-diabetes.
- A system to review historical alerts had been put into place with routine audit.
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