Background to this inspection
Updated
9 November 2021
Upwell Health Centre in Townley Close, Upwell, Norfolk, provides services to patients living in Upwell as well as the surrounding villages in the area covering over 100 square miles. Patients who live in excess of one mile from a pharmacy are eligible to have their prescribed medicines dispensed from the practice. Medicines can be collected from the practice or any of five designated outlets or delivered to their home. The dispensary has a dispensary manager and ten staff who work varying hours.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening
procedures, maternity and midwifery services, surgical procedures, treatment of disease, disorder or injury and family planning.
The practice has a website that contains information about what they do to support their patient population and the in house and online services offered.
Upwell Health Centre is situated within the NHS Norfolk and Waveney Clinical Commissioning Group (CCG) and provides services to approximately 10,720 patients under the terms of a primary medical services (PMS) contract. A PMS contract is a contract between NHS England and general practices for delivering primary medical services to the local community.
The National General Practice Profile states that 98% of the practice population is from a white background. Information published by Public Health England, rates the level of deprivation within the practice population group as three. On a scale of one to ten, level one represents the highest levels of deprivation and level ten the lowest.
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. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
The practice staff consist of six GP partners (three female and three male). Several advanced practitioners including: one advanced nurse practitioner (female), one long term conditions nurse (female), one paramedic (male), one physicians associate (female) The nursing team included a nurse manager (female), two practice nurses, (all female) and one health care assistant (female) and a nurse associate.
The administration team includes a practice and business manager, and quality manager. There were 13 staff members covering reception, administration and secretarial duties working a range of hours.
Telephone lines and reception are open from 8am to 6.30pm Monday to Friday.
The practice is one of 21 local GP surgeries who work to offer additional appointments to patients. The additional appointments are available at GP hubs in Terrington St John, King's Lynn and Swaffham.
When the surgery is closed the out of hours GP services are available via NHS 111.
Updated
9 November 2021
We carried out an announced inspection at Upwell Health Centre on 17 September 2021. Overall, the practice is rated as Good.
The ratings for each key question are:
Safe - Good
Effective – Good
Caring – Good – rating carried forward from previous inspection
Responsive – Good - rating carried forward from previous inspection
Well-led - Good
Following our previous inspection on 13 February 2020, the practice was rated Requires Improvement overall and for safe, effective and well-led key questions. The practice was rated Good for providing caring and responsive services, these ratings were carried forward from the previous inspection in March 2015 as the information we reviewed did not suggest the rating had changed.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Upwell Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up inspection to follow up on:
- Breaches of regulations and ‘shoulds’ identified in our previous inspection.
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/telephone 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 before and after the inspection
- A shorter 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 and Good for providing safe, effective and well-led services. We have rated all the population groups except for People with long-term conditions as Good.
We have rated the population group People with long-term conditions as Requires improvement.
We found that:
- The practice had responded appropriately to the concerns raised during the previous inspection in February 2020. We found they had reviewed and improved their governance processes and had implemented effective systems for the management of high-risk medicines monitoring, blood test results and safety alerts.
- We saw evidence of the practice monitoring their performance and clinical practice, this included an improvement in their prescribing of antibiotics.
- We found the provider did not have an effective system to monitor staff training. From records we viewed we saw that most staff had received domestic abuse training. However, we found gaps in adult safeguarding, infection prevention and control and Equality and diversity training.
- The practice had not achieved the minimum uptake target of 80% for cervical cancer screening. However, we found the practice had effective systems in place for inviting patients for their appointments and information we viewed during the inspection indicated an improving trend.
- The practice had reviewed and improved their systems to ensure that patients with a learning disability were invited for an annual health check. From records we viewed we saw evidence of good quality reviews for this patient group.
- We found that patients with poor mental health were being invited for reviews and had a comprehensive, agreed care plan documented in their record.
- Published data for long term conditions indicated that patients in this group did not always receive care and treatment in accordance with guidelines.
- We found 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.
- The provider was aware of the challenges the practice faced, including difficulties with recruitment and had implemented alternatives to provide safe care and treatment and be responsive to patients’ needs.
Whilst we found no breaches of regulations, the provider should:
- Review and improve their systems to monitor and manage staff training.
- Review and improve domestic abuse training, so that all staff are aware of what action to take to better support patients.
- Continue to improve uptake with cervical cancer screening.
- Continue to improve the management of patients with long term conditions, Learning disabilities and those patients with poor mental health.
- Continue to monitor and improve prescribing of medicines where prescribing is higher than expected to support medicines optimisation.
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