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Hilltops Medical Centre Good

Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Hilltops Medical Centre on 9 September 2021. 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 Hilltops Medical Centre, you can give feedback on this service.

Inspection carried out on 3 August 2021

During an inspection looking at part of the service

We carried out an announced inspection at Hilltops Medical Centre between 29 July and 3 August 2021. Overall, the practice is rated as good.

The ratings for each key question are:

Safe - Good

Effective – Good

Well-led – Good

Following a previous focused inspection on 15 October 2019, the practice was rated requires improvement overall and with a rating of requires improvement for providing safe and well led services and a rating of good for providing effective services and for all population groups.

We then carried out a remote review of Hilltops Medical Centre on 9 December 2020. This was undertaken to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in Regulation 12 safe care and treatment as set out in a requirement notice following our inspection in October 2019.

As a result of continued breaches of regulation being identified at our remote review a warning notice was issued to the provider in December 2020.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hilltops Medical Centre 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 safe, effective and well-led key questions
  • The breaches of regulation and ‘shoulds’ identified in the previous inspection. These are areas where we identified the provider should make improvements.

The practice had previously been rated good for the Caring and Responsive key questions following our comprehensive inspection on 26 November 2018.

The information we received and reviewed as part of this inspection did not indicate the previous rating of good for providing caring and responsive services was affected and therefore these ratings were carried over.

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 and telephone calls.
  • 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.
  • Asking patients to submit online feedback.

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 and for all population groups.

We found that:

  • The breaches in regulation issued in our warning notice in December 2020 had been met.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had processes for managing risks, including safety alerts.
  • The practice identified and learnt from significant events.
  • Patients received effective care and treatment that met their needs.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • They had made improvements to governance arrangements and managing risks. Practice policies and procedures were followed.

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

  • Continue to embed the implementation of the new online practice portal, particularly in relation to the management of significant events.
  • Seek innovative ways to improve patient outcomes in the Quality and Outcomes Framework.
  • Take actions to improve the levels of patient satisfaction particularly in relation to telephone access and appointment booking.
  • Seek innovative ways to encourage eligible patients to have cervical cancer screening.
  • Ensure information about the Parliamentary and Health Service Ombudsman is included in all complaint final response letters.

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

Inspection carried out on 9 December 2020

During an inspection looking at part of the service

We carried out a remote review of Hilltops Medical Centre on 9 December 2020. This was undertaken to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in Regulation 12 safe care and treatment as set out in a requirement notice we issued to the provider in October 2019.

The practice received an overall rating of requires improvement at our inspection on 15 October 2019. During this inspection safe, effective and well led domains were inspected with a rating of good for effective and all population groups and a rating of requires improvement for safe and well led services. These ratings will remain unchanged until we undertake an inspection that includes a site visit.

The report on the inspection carried out in October 2019 can be found by selecting the ‘all reports’ link for Hilltops Medical Centre on our website at www.cqc.org.uk

This report details our findings following the remote review of Hilltops Medical Centre undertaken 9 December 2020 as part of our transitional monitoring approach (TMA details on https://www.cqc.org.uk/guidance-providers/how-we-inspect-regulate/transitional-monitoring-approach-what-expect ) to follow up on risks identified both from the previous inspection and our own intelligence monitoring. This inspection looked at the following key questions:

  • Safe
  • Well-led

During this remote review we asked the practice to comment on the lower than expected patient satisfaction to the latest GP survey in relation to the caring and responsiveness domain and looked at the practice complaints log.

We did not include the Effective domain in this remote review as it was rated Good in our previous inspection of 15 October 2019.

We did not undertake a site visit as part of this review.

We reviewed the quality of care at this service on a combination of:

  • information from our ongoing monitoring of data about services
  • information from the provider, patients, the public and other organisations and
  • information from a remote review of clinical records and telephone interviews with staff.

Our key findings were as follows:

  • There was evidence work had been undertaken to improve infection prevention and control (IPC) standards.
  • Staff spoke about improvements to governance systems and the management of policies and protocols, these included improvements to appraisal systems and risks associated with chemical or substances hazardous to health (COSHH).
  • Improvements had been made to ensuring appropriate recruitment checks were undertaken for staff.
  • There had been insufficient action taken to seek assurance on staff immunity status to reduce the risks to patients and staff.
  • A systematic approach to the management and review of medicines safety alerts was still lacking.

The areas where the provider must make improvements as they are in breach of regulations:

  • Ensure care and treatment is provided in a safe way to patients. (Please refer to the enforcement section at the end of the report for more detail.)

The areas where the provider should make improvements are:

  • Review systems for the management of significant events and complaints to ensure a consistent approach is demonstrated in responding to incidents and maintaining records.
  • Monitor patient satisfaction and drive improvement in performance, particularly relating to access.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 15 October 2019

During an inspection looking at part of the service

We carried out an announced inspection at Hilltops Medical Centre on 15 October 2019 as part of our inspection programme. We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Well-led

At the last inspection in November 2018 we rated the practice as good overall and requires improvement for providing safe services because:

  • Risks to patients and staff had not adequately been assessed and monitored, in particular with regard to infection prevention and control and blank prescription stationery security.
  • The practice did not evidence a consistent approach to recruitment through the provision of appropriate recruitment records.

At this inspection, we found that the provider had taken some action to improve in these areas. In particular, concerns with blank prescription stationery security had been resolved.

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 requires improvement overall and good for all population groups. The practice was rated as requires improvement for providing safe and well-led services.

We found that:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The way the practice was clinically led and managed promoted the delivery of high-quality, person-centre care.
  • There was a clear leadership structure. However, support for effective practice management was lacking. The practice proactively sought feedback from staff and patients, which it acted on.
  • There was evidence of continuous learning and improvement at all levels of the organisation.

We rated the practice as requires improvement for providing safe services because:

  • Systems and processes to reduce risks to patient and staff safety needed strengthening.
  • Risks to patients and staff had not adequately been assessed, in particular those relating to staff immunity status, infection prevention and control, appropriate background checks for staff, significant events and safety alerts.

We rated the practice as requires improvement for providing safe services because:

  • Systems and processes to reduce risks to patient and staff safety were lacking.
  • There was limited evidence of improvements made following our inspection in November 2018.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Undertake risk assessments for any storage of hazardous substances for example, liquid nitrogen, storage of chemicals.
  • Ensure all policies, procedures and protocols are regularly reviewed and appropriate for implementation.
  • Maintain accurate recruitment records in line with practice policy and legislative requirements.
  • Complete timely appraisals for all staff.
  • Improve the support and implementation of practice managerial functions.

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

Inspection carried out on 26 November 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating 10/2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Hilltops Medical Centre on 26 November 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The practice had some clear systems to manage risk so that safety incidents were less likely to happen. However, there were some areas that were in need of strengthening. In particular, risks in relation to infection prevention and control needed review. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients we spoke with reported some difficulties with the appointment system and reported that they were not always able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements is:

  • Ensure care and treatment is provided in a safe way to patients. (Please refer to the requirement notice section at the end of the report for more detail).

The areas where the provider should make improvements are:

  • Provide appropriate non-clinical staff with training on sepsis.
  • Undertake regular fire drills.
  • Implement the newly developed appraisal system and complete staff appraisals for all staff in line with practice policy.
  • Embed newly adopted processes for ensuring practice oversight of clinical registrations
  • Continue with efforts to improve patient satisfaction and performance in the national GP patient survey; with particular regard for patient experience during consultations.
  • Complete the proposed auditing of practice policies and procedures to ensure they are up to date and relevant.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 27 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hilltops Medical Centre on 27 May 2016. Overall the practice is rated as good.

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

  • The practice had an open and transparent approach to safety, including the reporting and recording significant events.
  • Risks to patients were assessed and generally well managed. However, we found that the medication review process neded to be more robust.
  • The system for cascading and implementing medical updates and alerts would benefit from review. Evidence to identify the action the practice had taken in response to updated guidance and thereafter updating records was not always clear.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, we noted that not all clinical staff had a comprehensive understanding of the requirements to establish parental responsibilities before treatment was provided.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Feedback from patients was positive about the care and approach from staff. However, some identified concerns regarding accessibility of appointments. We saw that urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure, with partners and senior managers providing supportive and proactive direction for the practice. We noted that the CQC Registered Manager position was vacant at the time of inspection. The provider was in the process of applying for a new manager to be appointed.
  • Staff told us they felt supported by the partners and senior management. The practice routinely sought feedback from staff and patients from a variety of sources, which it acted on to improve services.
  • The provider was aware of and complied fully with the requirements of the duty of candour and had created and maintained a duty of candour log.

The areas where the provider should make improvement are:

  • Ensure robust systems and processes are in place for management of patient safety alerts and medication reviews, to ensure all discussions and actions are recorded appropriately
  • The practice should continue to monitor and seek improvements in outcomes for the National Patient Survey.
  • Consider a documented business plan to support the practice vision and strategy.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice