Wensum Valley Medical Practice West Earlham Health Centre

Updated 5 December 2022

Wensum Valley Medical Centre West Earlham Health Centre is situated in a purpose-built health centre, also known as West Earlham Health Centre, in the West Earlham area of Norwich, Norfolk. The practice has two branch sites at Adelaide Street Health Centre and Bates Green Health Centre.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.

The practice is situated within the Norfolk and Waveney Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 12,650. This is part of a contract held with NHS England. The practice is part of a wider network of GP practices (One Norwich Practices).

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 91% White, 4% Asian, 2% mixed, 2% Black, and 1% Other.

The practice has a partnership of three GPs. In addition to the GP partners there are four salaried GPs and two long term locum GPs employed at the practice. The clinical team includes four nurses and there are three Advanced Nurse Practitioners within the nursing team. There are two Practice Managers. The practice is supported by a team of staff who cover reception, administration, secretarial and patient care co-ordination roles.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations however if the GP needs to see a patient face-to-face then the patient is offered an appointment with a clinician suited to their needs.

The main practice site at West Earlham Health Centre is open between 8am and 6pm Monday to Friday. Patients can also be seen at the practice branch sites at Adelaide Street (open on Mondays, Tuesdays, Wednesdays and Fridays) and Bates Green Health Centres (only open on Tuesdays and Thursdays) which are open between 9am and 5pm.

Patients can access appointments on evenings and Saturdays at two local practices through the Primary Care Network. In addition, when the practice is closed patients are directed to the GP out of hours service which is accessed through the NHS 111 service.

Updated 5 December 2022

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