Archived: Vicarage Lane Health Centre

We carried out an announced comprehensive inspection at Vicarage Lane Health Centre on the 14 August 2019 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us.

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 inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The provider had ineffective systems in place for the management of infection control, medicines management, risk management, recruitment, referral management and record management and this put patients at risk.

We rated the practice as inadequate for providing effective services because:

• The practice did not have an effective system to monitor QOF performance, there was limited quality improvement activity, staff training was not routinely monitored and staff performance was not managed effectively.

We rated the practice as inadequate for providing responsive services because:

• The practice had not made sufficient improvements following the release of the GP patient survey and the complaints process was not easily available to patients and not followed by the practice in a timely manner.

We rated the practice as inadequate for providing well-led services because:

• The leaders did not demonstrate they could work together to set direction for the practice, there was no realistic strategy to deliver the practice vision, risks management and governance systems were not effective and performance data was not used to drive improvements.

These areas affected all population groups so we rated all population groups as inadequate.

We rated the practice as requires improvement for providing caring  services because:

• There was limited action to review and improve the patient experience.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review and improve the identification of patients who act as carers.
• Review the child immunisation results to ensure they meet the World Health Organisation targets.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care