During an assessment under our new approach
Date of Assessment: 11 March 2025 to 28 April 2025. Albion Health Centre is a GP practice and delivers service to 9,550 patients under a contract held with NHS England. The National General Practice Profiles states that 31.87% of people are white, 53.97% Asian, 6.03% Black, 4.35% Mixed and 3.84% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the second lowest decile (2 of 10). The lower the decile, the more deprived the practice population is relative to others. The practice is part of East End Health Network primary care network (PCN). 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. Scores were reached based on evidence found at this assessment.
The service was in breach of the legal regulation relating to safe care and treatment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
At this assessment, our clinical records reviews indicated that people with long term conditions and those on high-risk medicines were not followed up in line with guidelines and recommendations. We found that systems to deliver safe care were not always effective, in particular, health and safety, infection prevention and control, medicines management and staff training.
SAFE: This is the first assessment for this provider under our new ways of reporting. Shortfalls were identified in health and safety processes. The risks to people had not always been identified and/or mitigated. This included ensuring that the premises were safe for use. Areas of the environment needed refurbishment to make sure they could be effectively cleaned and reduce the risk of infection. Staff had not always managed medicines well. Consistency in the monitoring of people’s medicines was needed to make sure blood tests and physical checks were carried out prior to a review or prescription being issued. Not all staff had received safeguarding training relevant to their role. Managers had not made sure staff received training to maintain high-quality care. People could raise concerns and there were processes to ensure that learning happened when things went wrong. Managers investigated incidents thoroughly. Leaders acknowledged the safety concerns we identified during the assessment and took them very seriously. After the assessment, the provider informed us of actions they had taken to strengthen systems and processes. We will review these at our next assessment.
EFFECTIVE: People were mostly involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. However, people’s records did not always accurately reflect their health needs and how these needs would be met. There were shortfalls in monitoring people with long term conditions. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity. The service was below the national targets for the uptake of childhood immunisation and cervical screening.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. There was partnership working to make sure that care and treatment met the diverse needs of communities. People were encouraged to give feedback, which was acted on and used to deliver improvements. The service provided information people could understand. Leaders and staff worked to eliminate discrimination. However, patient feedback was mixed about accessing the service. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL-LED: The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Processes, and systems to support good governance were in place but not fully embedded into practice. Leaders did not always have a good understanding of how to make improvement happen. The approach to measuring outcomes and impact was inconsistent. The leaders had not ensured that staff always followed prescribing policies and evidence-based guidelines. Systems were not effective in identifying, mitigating and monitoring risk related to patients and staff including health and safety, infection prevention and control and staff training. Since our assessment we have received evidence of changes made in relation to governance and management of risks. We will review these changes at the next assessment to see if they are effective and have become embedded into practice.
The provider was aware that the premises needed refurbishment, and this was impacting on infection prevention and control and had developed plans on how to improve this, however, there was no confirmed date for when refurbishment work would commence. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. Staff felt supported to give feedback and were treated equally, free from bullying or harassment.