The Care Quality Commission
  • Doctor
  • GP practice

Barrow Health Centre

Overall: Good read more about inspection ratings

Health Centre , 27 High Street, Barrow-Upon-Soar, Loughborough, Leicestershire, LE12 8PY (01509) 274430

Provided and run by:
Barrow Health Centre

All Inspections

During an assessment under our new approach

Date of Assessment: 1 September 2026. Barrow Health Centre is a GP practice and delivers services to approximately 9,040 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 95.5% White, 2% Asian, 1.8% Mixed, 0.4% Black and 0.3% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 10th decile (10 of 10). The lower the decile, the more deprived the service population is relative to others.
This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 12 quality statements from across all 5 key questions. 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.
Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience.
Staff prescribed, stored and administered medicines. Clinical searches found some inconsistencies in medicines monitoring and documentation processes. The service reviewed the findings and took prompt action, including completing additional patient reviews, strengthening monitoring arrangements and sharing learning across the practice.
Staff supported people to live healthier lives and monitored care and treatment to help ensure positive outcomes. Clinical searches demonstrated that care and treatment was delivered in line with evidence-based guidance. The provider monitored outcomes and used audit, recall systems and quality improvement activity to support patient safety and improve care.
Staff treated people with kindness, empathy and compassion and respected their privacy and dignity. Patient experience data demonstrated positive experiences of care and treatment.
The service had a clear vision and strategy, which considered the needs of the people using the service and the wider community. Staff understood their individual roles and responsibilities. Leaders demonstrated a commitment to continuous improvement and responded positively to the findings identified during the assessment. Following the clinical review, the service implemented additional governance and monitoring arrangements to strengthen oversight, improve documentation standards and support patient safety.

8 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We had carried out an announced comprehensive inspection at Dr NHR Simpson’s Practice on 2 March 2016. The overall rating for the practice was ‘requires improvement’. This was because the practice was rated as ‘requires improvement’ in the key questions of caring and responsive. The full comprehensive report on that inspection can be found by selecting the ‘all reports’ link for Dr NHR Simpson’s Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 8 March 2017 to check if improvements had been made. Overall the practice is now rated as ‘Good’.

Our key findings were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice was responsive to the needs of patients and tailored its services to meet those needs.
  • 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. However information about complaints was not on display in the patient waiting area.
  • Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • 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.
  • There was an emphasis on learning and improvement.
  • The provider was aware of and complied with the requirements of the duty of candour.

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

The provider should:

  • Make information on the complaints system available in the patient waiting area.

  • Continue to monitor patient satisfaction with the service provided, particularly with respect to the helpfulness of reception staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr NHR Simpson’s Practice, Barrow Health Centre on 2 March 2016. Overall the practice is rated as ’Requires Improvement’.

We previously carried out an announced comprehensive inspection of this practice on 24 June 2015. Breaches of legal requirements were found. After that inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

  • Regulation 12 HSCA (Regulated Activities) Regulations 2014 Safe care and treatment

  • Regulation 17 HSCA (Regulated Activities) Regulations 2014 Good governance

  • Regulation 18 HSCA (Regulated Activities) Regulations 2014 Staffing

This inspection was carried out to check that improvements to meet legal requirements planned by the practice after our comprehensive inspection on 24 June 2015 had been made.

Our key findings across all the areas we inspected were as follows:

  • We found at this inspection of 2 March 2016 that improvements had been made since the previous inspection of April 2015 when the practice had been rated as Inadequate and placed in special measures.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients, including infection prevention and control were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • There was a safe process in place to manage incoming clinical mail.
  • There was a comprehensive business continuity plan in place.
  • Staff had been appropriately recruited and received the training required to enable them to fulfil their roles.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs, although there were issues with the telephony and appointment availability that were recognised by the practice and were being addressed.
  • 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 areas where the provider should make improvement are:

  • The provider should ensure there is a process for recording the serial numbers of prescriptions pads.

  • The practice should continue to address the concerns of patients with regard to the difficulty in accessing the service due to the telephone system.

  • Undertake their own surveys of patients to asses their satisfaction with the service provided.

I confirm that this practice has improved sufficiently to be rated ‘Requires Improvement’ overall. I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr NHR Simpson’s Practice on 24 June 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate in providing safe, effective, responsive and well-led services and requiring improvement for providing caring services. It was also inadequate in providing services for all the population groups.

Our key findings across all the areas we inspected were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe, for example, appropriate recruitment and accreditation checks.
  • There was no evidence of any induction process for nursing and HCA (Health Care Assistant) staff.
  • Staff were clear about reporting incidents, near misses and concerns, however the investigation of such was not sufficient for learning and preventing re-occurrence.
  • There was insufficient assurance to demonstrate people received effective care and treatment. For example there was no evidence of practice protocols for the management of illnesses such as hypertension, diabetes, chronic kidney disease or asthma.
  • Patients said they felt the practice offered an excellent service and staff were efficient, helpful and caring.
  • Urgent appointments were usually available on the day they were requested. However patients said that it was difficult to get through by telephone.
  • The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
  • The business continuity plan was not personalised to the practice and had no contact details completed should an emergency arise.
  • Multi-disciplinary team meetings were not in place to discuss vulnerable adults and children.
  • Medication checks were not being evidenced and there were no clear guidelines for staff to work from.
  • The incoming mail including correspondence relating to patients was being prioritised by non-clinical administrative staff with no formal process or procedure to work to.
  • There had not been an infection prevention control audit since 2012.

The areas where the provider must make improvements are:

Action the provider MUST take to improve:

  • Address identified concerns with infection prevention and control practice.
  • Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.
  • Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
  • Ensure staff have appropriate policies, protocols and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice including the Business continuity plan to be updated and personalised to the practice.
  • Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
  • Ensure that full investigations of serious incidents are undertaken and actions and lessons learned are taken to prevent reoccurrence. Also to demonstrate candour where necessary.
  • Ensure that there is a process for incoming mail that is robust and clinically safe.
  • Ensure recruitment arrangements include all necessary employment checks and staff are adequately trained to perform their roles, such as chaperone training and mental capacity training.
  • Put systems in place to ensure medications are checked to ensure that drugs are safe and are within the manufacturers expiry dates.
  • Update registration details for provider, partners and registered manager.

Action the provider SHOULD take to improve:

  • Improve processes for making appointments.
  • Ensure complaints and significant events are regularly discussed.
  • Multi-disciplinary meetings should commence to discuss the safeguarding of vulnerable patients.
  • Ensure there is a policy for the management of Legionella and undertake an assessment of the risk from Legionella.
  • Process and policy to identify and monitor risks to patients, staff and visitors to the practice.
  • Recall processes to be built and embedded in practice for the management of long term conditions.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice