During an assessment under our new approach
Date of Assessment: 19 May 2025 to 20 May 2025. The Primary Care Centre is a GP practice and delivers services to 3700 patients under a contract held with NHS England. The National General Practice Profiles states that 41.84% of patients are White, 37.54% Asian, 10.53% Black, 5.65% Other and 4.44% Mixed. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 1st decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: The service had improved their learning culture and people could raise concerns. Systems had been implemented to ensure incidents were thoroughly investigated. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed the majority of medicines well; however, we found further improvements were needed in the management of long term conditions and medicines that required regular monitoring to ensure people received the appropriate reviews and care.
EFFECTIVE: Improvements were seen in how people’s health conditions were managed, however further strengthening was required to ensure people were involved in assessments of their needs and the appropriate monitoring was in place. We found clinical supervision was now in place to monitor staff in clinical roles. Staff involved in assessments ensured people’s communication, personal and health needs were met. Care was based on latest evidence and good practice, however we found evidence based guidance was not always followed. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: We found significant improvements in how people were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL LED: Significant improvements were seen in how the practice was being managed and how leaders and staff had a shared vision and culture based on listening, learning and trust. Since the last inspection, the provider had formed a new partnership with 3 other GPs to further develop the practice, ensure they were sustainable succession plans in place and to improve the overall quality of services. A new practice manager had also been employed to oversee the day to day running of the practice and provide support to staff within their roles. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.
Since the last inspection, the practice had made improvements and is no longer in breach of regulations 12 Safe Care and Treatment, 16 Receiving and Acting on Complaints and 17 Good Governance.
This service was placed in Special Measures on 22 November 2023. The provider demonstrated improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.