The Care Quality Commission
  • Doctor
  • GP practice

Hillsprings Health and Wellbeing Centre

Overall: Good read more about inspection ratings

Lovett Court, Rugeley, Staffordshire, WS15 2FH (01889) 582244

Provided and run by:
Horsefair Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Hillsprings Health and Wellbeing Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Hillsprings Health and Wellbeing Centre, you can give feedback on this service.

26 February 2020

During an annual regulatory review

We reviewed the information available to us about Hillsprings Health and Wellbeing Centre on 26 February 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

6 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hillsprings Health and Wellbeing Centre (known as Hillsprings Surgery) on 22 March 2016. The overall rating for the practice was Requires Improvement. We found two breaches of legal requirements and as a result we issued a warning notice in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Safe Care and Treatment

We also issued a requirement notice in relation to:

  • Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Good Governance

We undertook an announced focused inspection on 31 August 2016 to follow up on the warning notices. We found that the provider met legal requirements in relation to Regulation 12.

Both the full comprehensive report on the March 2016 and the focused inspection on 31 August 2016 can be found by selecting the ‘all reports’ link for Hillsprings Health and Wellbeing Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 6 April 2017. Overall the practice is now rated as good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they had been offered an appointment on the day they contacted the practice. Urgent appointments and pre-bookable appointments were also available.
  • 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 provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

However, there were areas practice where the provider should make improvements:

  • Ensure that patient records demonstrate that high risk medicines are being prescribed safely.
  • Formalise and record clinical supervision which takes place between the nurse practitioner and GP.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 August 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hillsprings Health and Wellbeing Centre on 22 March 2016. A breach of legal requirement was found and a warning notice was served. The practice sent us an action plan to say what they would do to meet legal requirements in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safe care and treatment.

We undertook a focused inspection on 31 August 2016. We visited Hillsprings Health and Wellbeing Centre to check that the practice had followed their action plan and to confirm they now met legal requirements in relation to Regulation 12. 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 Hillsprings Health and Wellbeing Centre on our website at www.cqc.org.uk.

Our key findings were as follows:

  • The practice had reviewed, updated or developed policies and discussed these with staff at practice meetings.
  • The practice had introduced a system to act upon medicines and equipment alerts issued by external agencies. Alerts were reviewed and appropriate action taken.
  • The practice had introduced an effective system to ensure the safe and proper management of patients prescribed high risk medicines. Patients prescribed these medicines were monitored in line with recommended guidance.
  • Vaccines were being stored in line with manufacturers’ guidance.
  • Infection control audits had been carried out at each site and action taken to address any identified issues.
  • All clinical equipment had been serviced / calibrated and reminders introduced to ensure these checks were carried out annually.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hillsprings Health and Wellbeing Centre on 22 March 2016. Overall the practice is rated as requires improvement.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, the practice did not review significant events for trends or themes. There was no evidence to support that learning and changes had become embedded into practice.
  • Risks to patients were not always assessed and well managed, such as the management of patients who took high risk medicines and it was also not clear if appropriate action had been taken following receipt of medicines and equipment alerts.
  • The practice did not have robust arrangements for identifying, recording and managing risks and implementing mitigating actions. For example, infection prevention and control measures and the correct storage of vaccines.
  • 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 told us they could usually get an appointment when they needed one, with urgent appointments available the same day. However, they told us their biggest challenge was getting through to the practice on the telephone.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

There were particular areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Introduce robust systems to monitor patients who are prescribed high risk medicines.
  • Introduce a formalised system to act upon medicines and equipment alerts issued by external agencies.
  • Put systems in place to monitor when equipment is due for testing / servicing.
  • Ensure vaccines are always stored in line with manufacturers’ guidelines.
  • Review the emergency medicines held at all sites.
  • Introduce robust infection prevention and control measures that are in line with current nationally recognised guidance.
  • Put systems in place to ensure the learning and changes made as a result of significant events become embedded into practice.
  • Ensure that Patient Group Directives (PGDs) are up to date and current.
  • Risk assess the need for non clinical staff who chaperone to be subject to Disclosure and Barring Service checks.
  • Implement systems for assessing and monitoring risks across all three sites.
  • Introduce a system for recording and sharing information discussed at meetings to ensure staff are aware of their responsibilities in relation to any changes in policy or guidance.

In addition the provider should:

  • Review significant events and complaints for trends or themes.
  • Ensure that prescription forms are held securely at all times, including when in consulting rooms.
  • Ensure that the practice has a comprehensive record in place to cover staff recruitment.
  • Assure themselves that the landlord is carrying out all the necessary health and safety checks.
  • Investigate the reasons for, and where possible improve, lower than average rates of patients engaging in national cancer screening programmes.
  • Complete any outstanding staff appraisals and continue to review annually.
  • Share the practice vision and values with the staff team.
  • Evaluate the system for contacting the practice by telephone.
  • Ensure that clinical audit cycles are completed in order to prompt improvement in patient outcomes and consider other clinical quality improvement initiatives.
  • Adopt a more proactive approach to identifying and meeting the needs of carers.

Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

We carried out this review to follow up on one area of non-compliance from our previous inspection. We did not visit the service as part of this review or speak with patients or staff. However, we reviewed the action plan and additional information that the provider sent us detailing how they were going to address the issues.

The provider told us they had introduced a computerised stock control system within the dispensary. Medication was scanned in and out in order to maintain accurate records of stocks available. A protocol for the ordering, handling and storage of vaccines had been implemented and systems in place to monitor the temperature range of the refrigerators.

4 October 2013

During a routine inspection

On the day of our inspection we spoke with eight patients and six members of staff. Prior to the inspection we spoke with a spokesperson from the patient participation group (PPG) who was also a patient. PPGs are an effective way for patients and GP practices to work together to improve the service and to promote and improve the quality of the care. One patient told us, 'If I was in trouble, I would feel confident of getting the help I needed from here'. Another patient told us, 'The quality of care is brilliant here. It is really good'.

We saw that patient's views and experiences were taken into account in the way the service was provided and that patients were treated with dignity and respect. We saw that patients experienced care, treatment and support that met their needs. They were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening.

The provider had its own dispensary for patients who lived over one mile away from their nearest pharmacy. We saw that patients were not protected against the risks associated with medicines because the provider did not have effective systems in place to ensure that medicines were in date. We saw that there was no system in place to record when medicines came into or went out of the dispensary.

We saw that there were effective recruitment and selection processes in place. This meant that patients were cared for by suitably qualified, skilled and experienced staff.

The provider had an effective system to regularly assess and monitor the quality of the service that patients received.