This service is rated as Good overall. (Previous inspection 19 March 2018 – Unrated)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at St Mary's Medical Centre on 26 April 2019 to follow up on breaches of regulations. CQC inspected the service on 19 March 2018 and asked the provider to make improvements regarding breaches of 12 (Safe care and treatment) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We checked these areas as part of this comprehensive inspection and found this had been resolved.

The St. Marys Medical Centre is an independent health service based in Stratford, East London, providing adult and children patients consultations, treatment, and referrals where needed.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. St Mary's Medical Centre also provides massage which are not within CQC scope of registration. Therefore, we did not inspect, or report on these services.

Dr Ivelin Petrov Uzunov and Mrs Agnieszka Bilinska are the registered managers. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Feedback from a patient we spoke to and ten CQC patient comment cards showed patients found the service accessible and were satisfied with their care and treated with dignity and respect.

Our key findings were:

• 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.

• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider

should

make improvements are:

• Review and improve arrangements for specific types of records retention to ensure to ensure medical records are retained in line with Department of Health and Social Care (DHSC) guidance in the event the provider ceases trading.
• Review and improve arrangements to ensure clinical quality improvement activity is seen through and embedded.
• Review and improve timescales set out in the complaint’s procedure.
• Review and improve signposting arrangements for patients attempting to access care and treatment out of hours when the service is closed.
• Review and improve arrangements to formalise the process for non-clinical staff continuous professional development.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection on 19 March 2018 to ask the service the following key questions: Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was not providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was not providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was not providing well-led care in accordance with the relevant regulations.

Background

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The St. Marys Medical Centre is an independent health service based in Stratford, East London, providing consultations, treatment and referrals for patients who primarily come from Poland, Russia and Bulgaria.

Our key findings were:

• Most risks were identified and well managed but there were gaps or weaknesses including for patients cervical screening (smear tests), emergency medicines, staff checks, and infection control.
• The service did not monitor or take steps to the improve effectiveness of the clinical care it provided.
• Care and treatment was delivered according to evidence- based guidelines but there was no method to ensure guidelines we cascaded to relevant staff.
• There were no significant events or complaints but systems were in place to identify and manage them appropriately.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There were systems protect people from avoidable harm and abuse.
• Staff were qualified and had the skills, experience and knowledge to deliver effective care and treatment.
• There was a clear leadership structure and staff felt supported by management and worked well together as a team.

We identified regulations that were not being met and the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

• Review and improve arrangements to ensure a fire safety lead is on duty and appropriately trained.
• Review and improve the website to ensure services provided are clear.
• Review and improve arrangements to assess strategy and meeting outcomes.
• Review and improve arrangements for clinical staff induction.
• Review and improve arrangements to ensure appropriate children’s privacy.
• Review and improve verification of identity of parents or guardians for patients that are children.