The Care Quality Commission
  • Doctor
  • GP practice

The Centre Surgery Also known as Hinckley Health Centre

Overall: Good read more about inspection ratings

29 Hill Street, Hinckley, LE10 1DS

Provided and run by:
Hinckley & Bosworth Medical Alliance Limited

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Centre Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Centre Surgery, you can give feedback on this service.

17 June 2022

During a routine inspection

We carried out an announced inspection at The Centre Surgery on 17 June 2022 Overall, the practice is rated as good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 6 January 2022, the practice was rated Inadequate overall and for key questions safe and effective. Well led was rated as required improvement and caring and responsive were rated as good. The practice was issued with a warning notice in relation to regulation 12 (safe care and treatment) and a requirement notice in relation to regulation 17 (good governance).

A follow up focussed inspection was conducted on 14 April 2022 in relation to the breach of regulation 12 found at the inspection. We found that most of the issues had been addressed. A further requirement notice was issued in relation to regulation 12 at the inspection in April 2022.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Centre Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

:

  • Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection
  • Ratings carried forward from previous inspection in relation to safe, effective and well led.

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 evidence from the provider
  • 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 provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

  • Previous breaches of regulation had been met fully and patients’ needs were being met.
  • We found the practice had implemented governance structures and processes to ensure systems were kept safe.
  • We found the practice had made improvements to managing patients care and treatment in relation to prescribing and monitoring their medicines.
  • Backlogs of work which were previously found had been cleared and there were clear systems to ensure results and correspondence were dealt with appropriately in a timely matter.
  • There were clear systems to raise and investigate complaints and significant events with learning points shared to all staff.
  • Staff were positive about the changes which had been put in place and reported the management structure was effective at identifying responsibilities.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Undertake a review of historical safety alerts to ensure patients are not potentially affected by them.
  • Improve cervical screening uptake rates within the practice.

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 Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

4 Mar 2022 9 Mar 2022

During an inspection looking at part of the service

We carried out an announced focussed inspection at The Centre Surgery on 4th and 9th March 2022 to review compliance with a warning notice which was issued following our previous inspection in January 2022.

In January 2022, the practice was rated as inadequate overall and also for the key questions of safe and effective. The practice was placed into special measures. This inspection on 4 and 9 March 2022 was undertaken to review compliance with the warning notices which had to be met by 28 February 2022, but the inspection was not rated. The ratings from January 2022 therefore still apply and will be reviewed via a further inspection to take place within the next six months.

The key questions are rated as:

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive - Good

Well-led – Requires Improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Centre Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a focused inspection to follow up on the warning notice issued in respect of breach of regulation 12 (safe care and treatment).

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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

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 have not rated this practice as the rating remains unchanged until we have completed a further inspection incorporating all relevant key questions.

However, we found that action had been taken to address the breaches identified in the warning notice and it was evident that improvements had been made.

  • We found no evidence of undiagnosed conditions in patients we reviewed.
  • Patients with long term conditions were being managed appropriately in line with national guidance.
  • DNACPR records were completed and recorded for patients.
  • The practice had a system in place to deal with incoming test results and correspondence.
  • There was a system for clinical oversight of non medical prescribers however it had yet to be embedded due to no non-medical prescribers currently working within the practice.

However, we found that some areas required actions were ongoing and were not yet fully completed or embedded.

  • We saw that most medicines were being monitoring in line with national guidance, however some medicines still required some monitoring to be completed more frequently in line with national guidance.
  • The practice had not reviewed historical safety alerts to identify if any patients were potentially at risk of harm.
  • Medication reviews had been completed for patients who took multiple medicines, however they did not always contain detail of which medicines had been reviewed.

As a result, the areas where the provider must make improvements are:

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

Whilst we found no breaches of regulations, the provider should:

  • Continue to implement a system in relation to clinical oversight of prescribers within the practice.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

16/11/2021, 22/11/2021

During a routine inspection

We carried out an announced inspection at The Centre Surgery on 16 November 2021. Overall, the practice is rated as inadequate.

The key questions are rated as:

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive - Good

Well-led – Requires Improvement

Why we carried out this inspection

This inspection was a comprehensive inspection as part of our inspection programme. The service first registered with CQC in August 2018 and this was our first inspection of this location.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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 evidence from the provider
  • 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 provider, patients, the public and other organisations.

We have rated this practice as inadequate overall

We rated safe as inadequate because:

  • The practice did not always provide care in a way that kept patients safe and monitored their treatment in line with national guidance.
  • There was a lack of comprehensive medication reviews completed for patients taking regular medicines.
  • There was no formal recorded supervision of clinicians within the practice.
  • Significant events were not always acted on or investigated.

We rated effective as inadequate because:

  • Care and treatment did not always reflect current evidence based guidance and there was a lack of evidence that guidance updates were discussed within the practice.
  • Patients long term conditions were not always monitored in line with guidance.
  • Not all staff had completed training for their role and there was a lack of oversight over training.
  • There were gaps within completing appraisals of clinical staff.
  • DNACPRs were not always completed in line with national guidance.

We rated well-led as requires improvement because:

  • A lack of vision and values within the practice
  • There was a lack of governance and oversight in areas of the practice such as clinical oversight, health and safety oversight and infection prevention and control.
  • The practice had not always identified risks or had assurance that actions had been completed.
  • There was a lack of continuous development within the practice

We rated caring and responsive as good because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found two breaches of regulations. The provider must:

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

Whilst we found no breaches of regulations, the provider should:

  • Improve accessibility at the reception area for patients who use a wheelchair.
  • Improve uptake rates for cervical screening.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care