The Care Quality Commission
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Wensum Valley Medical Practice West Earlham Health Centre

Overall: Requires improvement read more about inspection ratings

West Earlham Health Centre, West Earlham, Norwich, Norfolk, NR5 8AD (01603) 250660

Provided and run by:
Wensum Valley Medical Practice

All Inspections

3 November 2022

During a routine inspection

We previously carried out an announced comprehensive inspection at the practice on 1 March 2022. The practice was rated as inadequate overall and placed into special measures. As a result of the concerns identified, we issued the practice with a warning notice relating to a breach of regulation requiring them to achieve compliance with the regulation by 15 June 2022. We undertook a focused review on 27 June 2022 to check that the practice had addressed the issues in the warning notice, and we found they had met the legal requirements.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Wensum Valley Medical Centre West Earlham Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive inspection on 3 November 2022 to follow up breaches of regulation and shoulds from a previous inspection.

Overall, we have rated the practice as Requires Improvement

  • Safe - requires improvement.
  • Effective - requires improvement.
  • Caring - good.
  • Responsive - good.
  • Well-led - requires improvement.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Staff questionnaires.

Our findings

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 found that:

  • The practice and leaders had been fully engaged with the external support provided by the Integrated Care Board (ICB). They were working to a clear action plan and had made improvements. These improvements had been newly established and required further time to be fully implemented, embedded and monitored to ensure improvements would be sustained.
  • The clinical oversight had been improved and the leaders had greater awareness of their responsibilities in driving and monitoring the improvements needed. They had developed a new management structure which needed to be embedded and gain experience to ensure safe and effective services were delivered.
  • The governance framework had been strengthened to identify and manage gaps or actions required that had been identified through risk assessments.
  • There continued to be evidence of low morale at the practice and evidence of a closed culture at times, although some staff told us this had started to improve. Although the practice had made improvements, these had not been wholly implemented, or had sufficient time to demonstrate effectiveness. There were gaps across practice systems to support safe, effective and well-led services.
  • The practice was reliant on external support staff to address all the issues and implement changes. The practice was in the process of recruiting new staff.

We found two breaches of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

In addition, the provider should:

  • Support all clinical staff to attain level 3 safeguarding children training.
  • Continue to encourage uptake of cervical cancer screening appointments.
  • Continue to engage with patients to gain feedback to deliver appropriate services to the population.
  • Review and improve complaint response letters to patients and or relatives including contact details of where they may escalate their complaint if needed.

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.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

1 March 2022

During a routine inspection

We carried out an announced inspection at Wensum Valley Medical Practice, West Earlham Health Centre on 1 March 2022. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led – Inadequate

Why we carried out this inspection

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

During our inspection we identified issues relating to safe, effective and well-led services. Therefore, this inspection involved a comprehensive review of information with a short site visit.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting and reviewing evidence and information from the service
  • A short site visit

Our findings

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 service, patients, the public and other organisations.

We have rated this practice as Inadequate overall

We found that:

  • The practice was based in a deprived area with high levels of deprivation and patient groups with complex care needs. There was a high level of safeguarding referral and engagement, with evidence of safe and effective safeguarding systems in place to support this.
  • However, there was a lack of clinical oversight in areas which impacted on other areas of safe and effective patient care. There were gaps across the practices systems and processes to support safe use of medicines, managing test results and for managing medicines safety alerts.
  • The practice did not have an effective system in place to learn and make improvements when things went wrong.
  • The governance and lines of accountability within the practice were not always clear. There were gaps in governance and management of risk across some systems and processes.
  • Verified and published data as well as unverified practice data provided during our inspection, highlighted that their cervical screening uptake remained below National target rates.
  • During the inspection the practice was able to demonstrate that they had made some efforts to improve their prescribing rates for hypnotic and psychotropic medicines as well as the uptake of certain childhood immunisations.
  • Staff understood the complexities of their practice population, we saw examples of a caring approach towards patients.
  • The practice could directly refer patients into their wellbeing service and to a mental health nurse practitioner, physiotherapist and social prescriber who were available on site, one day a week.
  • There was a lack of evidence to demonstrate active patient, public and staff engagement, and some evidence indicated a closed culture at times with low morale across staffing areas.
  • The provider could not demonstrate a clear practice vision.

We found a breach of regulations. The provider must:

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

Additionally, the provider should:

  • Build on efforts to encourage attendance at cervical screening appointments, exploring ways of effectively engaging the practice population.
  • Continue to monitor and improve hypnotic and psychotropic medicine prescribing rates.
  • Strengthen systems for recording and reflecting on positive outcomes following quality improvement initiatives and clinical audits.
  • Consider adapting to the easing of restrictions in line with national guidance, reducing potential barriers to access for all population groups.

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

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.

We are considering enforcement action against this provider for a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12(1) Safe care and treatment.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

13 March 2018

During a routine inspection

This practice is rated as Good overall. At the previous Care Quality Commission (CQC) inspection in July 2017, the practice received an inadequate overall rating and was placed in special measures for a period of six months.

Our announced comprehensive inspection on 18 March 2018 was undertaken to ensure that improvements had been made following our inspections carried out in July 2017.

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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We previously carried out an announced comprehensive inspection at Wensum Valley Medical Practice on 12 October 2016. The overall rating for the practice was requires improvement (safe and effective were rated as requires improvement, caring, responsive and well-led all rated as good).

We carried out an announced focused inspection on 18 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection. However, insufficient improvements had been made and we subsequently carried out an announced comprehensive inspection on 24 July 2017 with a follow-up unannounced focused inspection on 31 July 2017 to assess the immediate actions taken. The practice were rated as inadequate overall (inadequate for safe and well led services and requires improvement for caring, effective and responsive services).

We carried out an announced comprehensive inspection at Wensum Valley Medical Practice

on 13 March 2018. This inspection was undertaken following the period of special measures and to confirm that the practice now met the standards in relation to the breaches in regulation (give breaches). Overall, the practice is now rated as good. The practice is no longer in special measures.

The full reports on the July 2017 and October 2016 inspections can be found by selecting the ‘all reports’ link for Wensum Valley Medical Practice on our website at www.cqc.org.uk.

At this inspection we found:

  • The practice showed evidence that they had been responsive to the findings of the previous report and had made significant improvements. The clinical leadership had been improved, all partners had been involved and practice staff we spoke with told us that they had been included in the development of the action plan and had been fully engaged in the changes made. The clinical commissioning group (CCG) had been engaged with and had supported the practice where appropriate. The practice had employed a new practice manager who had been fully in post since September 2017. The practice had also engaged a new partner and full time pharmacist, both of whom commence their posts on 1 April 2018.
  • The practice was clear on the improvements that had been achieved or were in process or being embedded. They had undertaken a significant number of audits to ensure the changes they had made had been effective.
  • The practice was aware of their population needs and the levels of deprivation that affected them. All staff had received training to become a dementia friendly practice.
  • We found the system in place for reporting and recording significant events and complaints had been improved, and embedded. Risk assessments had been undertaken in a systematic and organised way.
  • The practice had implemented a suite of practice specific policies and procedures which staff had read and were using. A new practice intranet system was in place and this was in the process of being fully populated.
  • The system in place to deal with and monitor patient safety alerts had been reviewed and improved, ensuring that patients were appropriately monitored.
  • The process to manage medicines prescribed to patients had been improved. A fully electronic system giving a clear audit trail of changes and clinical oversight had been implemented.
  • An effective system to manage correspondence had been implemented. Clear polices and protocols had been embedded to ensure that GPs saw all correspondence that required a clinical view.
  • A fully electronic system had been introduced to ensure that staff were employed safely and that training requirements were met. We found that all staff had received the training deemed mandatory by the practice.
  • Clinical oversight had been introduced to ensure that home visits were managed safely and in a timely manner.
  • Data from the Quality and Outcomes Framework showed patient outcomes in many areas were mixed with areas above, in line, or below the national averages. Some exception reporting was above the national averages. To ensure this was managed well, the practice had increased clinical oversight into reviewing, improving, and monitoring their performance.
  • The practice had increased the use of SMS messages to patients including where possible in the patients first language.
  • Results from the national GP patient survey, published in July 2017, showed the practice was in line with or below local and national averages for many aspects of care.
  • Since the last inspection the practice had engaged with patients and a patient participation group had been formed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18, 24 and 31 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Wensum Valley Medical Practice on 12 October 2016. The overall rating for the practice was requires improvement (safe and effective were rated as requires improvement, caring, responsive and well-led all rated as good). We carried out an announced focused inspection on 18 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection. However, insufficient improvements had been made and we subsequently carried out an announced comprehensive inspection on 24 July 2017 with a follow-up unannounced focused inspection on 31 July 2017 to assess the immediate actions taken.

The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Wensum Valley Medical Practice on our website at www.cqc.org.uk.

This report covers our findings in relation to those requirements and to the new concerns identified from the inspections on 18, 24 and 31 July.

Our key findings were as follows:

  • The practice was aware of their population needs and the levels of deprivation that affected them.

  • The practice served an area where deprivation was one of the highest in Norwich. Public Health England 2015 – 2016 data showed the deprivation affecting children scored 39% compared to the local clinical commissioning group (CCG) figure of 23% and the national figure of 20%.

  • The practice lacked clinical leadership to ensure it delivered high quality and safe care.

  • We found the system in place for reporting and recording significant events and complaints was not effective enough to ensure that all incidents had been recorded, learning from events was shared effectively with the practice team or changes made to improve the service. The opportunities to make early interventions to encourage improvement were missed.

  • The patients and practice staff were at risk of harm, the practice had not undertaken sufficient risk assessments to ensure they would be kept safe. For example the practice was not able to evidence they had undertaken risk assessments for fire or health and safety. The practice took immediate action to address these issues.

  • The systems and process to manage infection prevention and control needed to be improved.

  • The system in place to deal with and monitor patient safety alerts needed to be improved, as they did not have a system to ensure alerts were recorded for future monitoring.

  • The practice had a medicine review system in place to support patients who take medicines that require monitoring. However, we identified the medical records did not evidence which GP had reviewed the medicines and authorised that more prescriptions could be issued.

  • Patients were at risk of harm because the practice system to ensure GPs saw all relevant correspondence was not effective.

  • We saw doctors and nurses were appropriately registered and they had medical indemnity in place. However, the practice did not have systems and processes in place to easily monitor these requirements.

  • During our inspection we saw generic policies and procedures were in place. These policies had not been reviewed or amended to be practice specific.

  • Not all practice staff had received annual appraisals; nursing staff including those with a prescribing qualification had limited formalised clinical supervision with GPs and did not have one to one peer reviews. Some staff told us they felt isolated and that the communication within the practice could be improved.

  • We found there was not always a consistent approach to the allocation of home visits by non-clinical staff.

  • Data from the Quality and Outcomes Framework showed patient outcomes in many areas were below national averages. The practice exception reporting for 2015-2016 was higher than the local or national averages. The practice had discussed the high exception reporting as a team and had put some actions in place. However, there was no system in place to monitor any improvements to ensure they had been effective.

  • Results from the national GP patient survey, published in July 2017, showed the practice was in line with or below local and national averages for many aspects of care. The practice gathered regular feedback from patients.

  • Patients we spoke with said they did not find it easy to make an appointment with a named GP but urgent appointments were usually available.

  • The practice training log was not up to date and the practice was not able to evidence that all staff had received training they deemed mandatory, for example safeguarding training.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice supported and wrote regular articles for a local charity, the Henderson Trust, who produce a regular newsletter. For example, the practice wrote an article to encourage patients with pulmonary disorders such as asthma to attend their regular follow up appointments and avoid having to attend Accident and Emergency.

  • The practice worked with the local schools to encourage healthy lifestyles. Children from a nearby school had designed posters for a notice board in the waiting area.

  • The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the practice should make improvements are:

  • Complete all staff occupational health assessments to ensure the immunisation status of staff is recorded, or risk assessed.

  • Continue to explore ways to engage effectively with patients.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wensum Valley Medical Centre in Norwich on 12 October 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected 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 generally well managed. Improvement was needed in several areas, for example the record keeping on the cleaning of clinical equipment and the recording of staff immunisation status’.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had participated in end of life cooperative working with a local hospice for the evaluation and education of non-clinical staff.
  • 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 practice had shared its processes for dealing suspect non accidental bruising in babies with the local safeguarding team – who had commented this would be used for training GPs across Norfolk.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Ensure that the immunisation status of staff is recorded or, where deemed not required, risk assessed.
  • Continue to explore ways to encourage patients to attend for appointments and engage with national screening programmes for breast and bowel cancer
  • Embed and monitor the new practice policies and procedures and ensure that staff can access and use them.
  • Ensure that medicine reviews (including those for high risk medicines) are undertaken using a uniform approach.
  • Ensure that effective records on the cleaning of clinical equipment are in place.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29 January 2014

During a routine inspection

During our visit we spoke with 14 people who were using the service and with five relatives who were accompanying people who were attending the surgery. We also accompanied a GP when they visited and provided treatment to a person in their own home.

We found that care had been planned as part of an individual, person focused approach and was provided in a very person centred manner. We saw this when we observed treatment being given and when nurses and doctors greeted people and spoke to them.

We found that medical records were consistently detailed and included other health and social care professional's notes, which showed that strong collaborative working arrangements had been used to provide a person centred approach.

People were kept safe from abuse by well trained staff, who had a special focus in safeguarding children. Policies and procedures, and staff knowledge and training, assured us that children and vulnerable adults were appropriately protected from abuse because the provider had taken suitable action.

The premises were purposely designed for the collective activities of the nurse and GPs and had adequate working space for administrative staff. We saw that the premises were clean and had been well maintained.