We carried out an announced comprehensive inspection at Moore Street Medical Centre on 21 March 2019 as part of our inspection programme.

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 good overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of good quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Continue to review the protocol for the GP assistant role and ensure there is regular monitoring and auditing of this role.
• Review the system for monitoring two week wait referrals.
• Increase the number of carers identified to ensure these patients are offered appropriate advice and support.
• Monitor the effectiveness of the new appointments system.
• Review how complaints responses are provided to ensure patients are provided with all required information.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Details of our findings and the evidence supporting our ratings are set out in the evidence table

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at this practice on 8 October 2015.

A breach of legal requirements was found. The practice was required to make improvements in the domain of ‘Safe’.

After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Premises and equipment; and

Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Fit and proper persons employed.

We undertook this focused follow-up review to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Moore Street Medical Centre on our website at www.cqc.org.uk.

Our key findings were as follows:

• The practice had addressed the issues identified during the previous inspection.

• Arrangements to have electrical works completed at the practice had been made. We found some further work was still required. This was scheduled to be completed within 28 days of this follow-up inspection.

• Recruitment checks had been undertaken on any locums employed directly by the practice.

• The practice had responded positively to suggestions for improvements. For example, GPs had completed a risk assessment which explaind and supported the decision not to have a defibrillator at that practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Moore Street Medical Centre on 8 October 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. The practice was able to demonstrate a culture of learning, openness and transparency in relation to any significant events. Systems in place at the practice supported this.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day and open access surgeries each morning.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

• The practice had used month on month data to review the effectiveness of booked appointments versus open access surgeries. This was used to increase the flexibility of access to appointments. Practice leaders continued to review any attendance of patients at walk in centres or accident and emergency units, to confirm that levels of access for patients remained high.

• The practice recognised the risks posed to the safety of some patients through telephone triage, particularly those from more vulnerable groups and those with whom it was difficult to engage. For this reason the practice pursued face to face appointments for these patients, at times using a locum Advanced Nurse Practitioner to meet demand.

However there were areas of practice where the provider must make improvements:

• The practice must hold and retain records of all background checks in relation to directly retained locum GPs, in line with the requirements of Schedule 3.
• The practice must hold and retain certificates in respect of electrical safety of the practice.

Areas of practice where the provider could make improvements:

• The practice should conduct a risk assessment supporting the decision not to have a defibrillator available at the practice.
• All clinicians should record that a chaperone service had been offered to a patient were appropriate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice