This practice is rated as Requires Improvement overall. This is the first inspection for this practice.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Carnarvon Medical Centre on 20 November 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice involved patients in regular reviews of their medicines.
• There was an effective system for receiving and actioning safety alerts.
• We found the practice had appropriate systems in place to monitor medicines requiring refrigeration.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Staff had received training applicable to their role and the practice provided staff with ongoing support.
• We found the practice had conducted environmental risk assessments and completed actions identified.
• The practice had identified 0.78% of its practice list as carers by highlighting them during registration and clinical consultations.
• The practice was clean and tidy and staff had reviewed infection prevention control and policies.
• Data from the national GP patient survey published in July 2018 showed patients rated the practice in line with local and national averages for all aspects of care.
• We received 20 positive comment cards regarding the care and service at the practice and seven mixed reviews.
• The outcome data for people with long term conditions was lower than local and national averages.
• The uptake for cervical screening and child immunisations was lower than local and national averages.
• They had found it difficult to sustain a patient participation group.
• The practice had carried out a low number of clinical and non-clinical audits.
• There was no appraisal system in place for staff.
• Staff with chaperone responsibilities did not have a Disclosure and Barring Service (DBS) check and there were no risk assessments in place to mitigate any risk associated with this decision.

The areas where the provider must make improvements are:

Ensure care and treatment is provided in a safe way to patients.

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

• Continue to actively encourage patients to join the patient’s participation group. meet regularly.
• Increase the number of patients who are carers identified and provide them with appropriate support.
• Work towards improving patient uptake for cervical screening and childhood immunisations.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.