This practice is rated as requires improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Trentham Mews Medical Centre on 16 November 2018 as part of our inspection programme.

At this inspection we found:

• When incidents happened, the practice learned from them and improved their processes.
• Appropriate risk assessments had not always been completed.
• Fire drills had not been carried out at the practice.
• 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.
• Some staff had not completed training appropriate to their role.
• The practice had not carried out appropriate checks for all staff at the time of recruitment.
• Systems for receiving Medicines and Healthcare products Regulatory Agency alerts into the practice were in place but not always up to date.
• Staff involved and treated patients with compassion, kindness, dignity and respect. There was high patient satisfaction throughout the practice.
• The practice was pro-active in working with the local community to improve the health of its practice population.
• Patients found the appointment system very easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• There was a clear practice vision and strong set of values.
• Governance arrangements did not support the identification of potential risks or take action to mitigate them.

We saw two areas of outstanding practice:

• Data from the GP National Survey was above local and national averages in all indicators. One hundred per cent of respondents were positive about the overall experience of their GP practice.
• Since 1999 the practice had been active in promoting community engagement to improve health by creating supportive environments and strengthening community action. Current projects included the community book lending service and the establishment of a trust that supports the education and health care of children in a very deprived community in Uganda.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure specified information is available regarding each person employed.

Please refer to the requirement notice at the end of this report for more detail.

The areas where the provider should make improvements are:

• Update policies to ensure they reflect current guidance. For example, policies for safeguarding vulnerable adults and recruitment.
• Provide reception staff with training to identify the rapidly deteriorating patient.
• Implement and monitor changes required as identified in the infection control audit.
• Improve government arrangements and risk management processes so that they operate effectively.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

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