The Care Quality Commission
  • Doctor
  • GP practice

Ellergreen Medical Centre

Overall: Good read more about inspection ratings

24 Carr Lane, Norris Green, Liverpool, Merseyside, L11 2YA (0151) 256 9800

Provided and run by:
Ellergreen Medical Centre

All Inspections

During an assessment under our new approach

Date of Assessment: 11 September 2026. Ellergreen Medical Centre is a GP practice and delivers a service to 13,200 patients under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 90% White, 4.0% Asian, 2.0% Mixed, 2.8% Black and 1.2% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 1st decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. 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.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any identified risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. 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 worked with people close to the patient to make decisions in their best interests when they lacked capacity.

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.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. 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.

The service had a clear vision and strategy. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

Whilst we identified some governance and record keeping issues, including gaps in recruitment documentation and incident management processes, leaders took immediate action to address these concerns.

28 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of this practice on 12 November 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to Regulations:

  • Regulation 15 HSCA (Regulated Activities) Regulations 2014 Safety and suitability of premises.
  • Regulation 17 HSCA (Regulated Activities) Regulations 2014 Good governance.

We undertook this focused inspection on the 28 June 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements and issues identified in the previous report. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ellergreen Medical Centre on our website at www.cqc.org.uk.

Overall the practice is rated as good.

Our key findings were:

The practice had addressed the breaches of regulations and other issues identified during the previous inspection and made many improvements including:

  • New systems to ensure they were meeting Health and Safety legislation to ensure the safety of both patients and staff. Risk assessments for health and safety had been carried out and action had been taken against the risks identified such as gas, electrical and fire safety.
  • New systems to follow national guidelines for the cleaning of premises. There was monitoring of cleaning for the premises and clinical equipment and cleaning equipment had been renewed.
  • There was now a formalised practice plan and all staff were involved in discussions about policies and protocols at protected learning events.
  • The training matrix had been renewed and kept updated on a monthly basis which made it clear when staff training was due. All staff had received training relevant to their role and additional training had been attended for example, computer training.
  • The practice had employed a pharmacist who was helping the practice address the high level of hypnotic medication prescribing. The practice had managed to reduce antibiotic prescribing rates by 6.8%. The practice had introduced monitoring systems for uncollected prescriptions.
  • The practice had employed an information facilitator who had renewed the recall system and who liaised with the local mental health team to help ensure annual physical health checks for all patients experiencing poor mental health were completed and correctly recorded.
  • The practice was carrying out a rolling programme of GP and nurses’ consultation audits to ensure all clinicians are following appropriate guidance in relation to treatment and medical record keeping.
  • The practice had sought other ways of gaining patient feedback and had also conducted a staff survey.
  • The practice had considered further ways to improve patient satisfaction with regards to making appointments and looked at tackling the high patient fail to attend rate for appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ellergreen Medical Centre on 12 November 2015.

Overall the practice is rated as requires improvement.

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

  • The practice did not follow Health and Safety legislation to ensure the safety of both patients and staff. Risk assessments for health and safety had been carried out but no action had been taken against the risks identified such as electrical and fire safety.
  • The practice did not follow national guidelines for the cleaning of premises. There was no monitoring of cleaning for the premises or clinical equipment and cleaning equipment was not fit for purpose.
  • The practice analysed significant events. Information from these and complaints identified serious issues with poor record keeping and communications which the practice was in the process of addressing.
  • The practice had disabled access and facilities but no hearing loop. There was access to translation services.
  • The practice identified the needs of its population and worked well with other health and local community organisations such as paediatric nurses and citizens advice.
  • Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service, including having a patient participation group (PPG) but this had a limited membership. The practice acted on feedback from both patients and staff.
  • Staff worked well together as a team and all felt supported to carry out their roles. Staff we spoke with on the day had completed mandatory training but the training matrix identified gaps and it was unclear if this was simply due to poor monitoring. There was no clear strategy or business plans. There was a new practice manager and some policies and systems had been revised but there were further improvements needed.

Importantly, the provider must:

Have due regard to all Health and Safety legislation, and:

  • Put in place monitoring systems for cleaning of the premises to ensure the practice is following current guidelines and discard all dirty cleaning equipment such as dirty mops.
  • Carry out a control of substances hazardous to health assessment for all materials used.
  • Cary out any actions identified in health and safety risk assessments for example, in fire and Legionella risk assessments.
  • Carry out electrical safety checks for the building.

In addition they must:

  • Ensure their governance systems are effective by improving: policies, record keeping, staff training, monitoring systems, risk assessments and actions needed for health and safety.

There were improvements the provider should consider:-

  • Address the high level of hypnotic medication prescribing.
  • Carry out the remaining annual physical health checks for all patients experiencing poor mental health.
  • Carry out regular GP and nurses’ consultation audits to ensure all clinicians are following appropriate guidance in relation to treatment and medical record keeping.
  • Carry out patient and staff surveys.
  • Consider further ways to improve patient satisfaction with regards to making appointments and look at tackling the high patient fail to attend rate for appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice