23 September 2022
During a routine inspection
We carried out an announced comprehensive inspection at Grange Medical Centre on 22 and 23 September 2022. Overall, the practice is rated as Good
Safe - Good
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 5 April 2018, 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 Grange 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
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 some staff interviews using video/telephone 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 to both the main location and branch surgery.
- Reviewing completed staff questionnaires.
- Speaking with patients and reviewing their feedback.
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:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
- The practice adjusted how services were delivered to meet the needs of patients during the COVID-19 pandemic. Patients were able to access care and treatment in a timely way.
- There was a programme of quality improvement, this included clinical audit.
- Staff had the skills, knowledge and experience to deliver effective care.
- The practice had a good understanding of the needs of the local population and delivered services to meet these needs. In addition, they had engaged with the community to raise awareness of subjects and issues such as COVID-19, immunisation and healthy lifestyles.
- The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Leaders and managers in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
- There were mixed views from patients in relation to accessing services.
We found a breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients (refer to the requirement notice at the end of the report for more detail).
In addition, the provider should:
- Promote and increase uptake of cervical and bowel cancer screening.
- Improve patient engagement to understand and redress areas of low patient satisfaction in regard to patient consultations and access to services.
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