The Care Quality Commission
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  • GP practice

Upwell Health Centre

Overall: Good read more about inspection ratings

Townley Close, Upwell, Wisbech, Cambridgeshire, PE14 9BT (01945) 773671

Provided and run by:
Upwell Health Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Upwell Health Centre 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 Upwell Health Centre, you can give feedback on this service.

17 September 2021

During an inspection looking at part of the service

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

13/02/2020

During an inspection looking at part of the service

We carried out an announced focussed inspection at Upwell Health Centre on 13 February 2020 as part of our inspection programme. This was due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

•are services safe?

•are services effective?

•are services well-led?

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

•are services caring? - good

•are services responsive? – good

At the last inspection on 3 March 2015 we rated the practice as good overall. The full comprehensive report for this inspection can be found by selecting the ‘all reports’ link for Upwell Health Centre on our website at www.cqc.org.uk.

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.

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

•The systems to ensure patients prescribed high risk medicines were monitored appropriately were not always effective.

•The process for receiving and acting on patient safety alerts was not effective. At the time of the inspection, a patient safety alert from January 2020 had not been received and actioned. Following the inspection, the practice told us this alert had been received and action was being taken.

•There was no clinical oversight of blood test results which had been requested by the midwife; these dated back to January 2020.

We rated the population groups of people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia) as requires improvement because:

•We did not see documented evidence that patients with a learning disability had received an annual health check in the past 12 months.

•The practice was not able to demonstrate that all patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in their record or had been invited for a review.

•Due to the ratings principles, the practice is rated as requires improvement for providing effective services. All other population groups were rated as good.

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

•The leadership did not ensure all systems and processes were in place to ensure patients received safe and effective care.

The areas where the provider must make improvements are:

•Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

•Staff should receive training in line with the practice domestic abuse policy.

•Continue work to review and improve the prescribing of non-steroidal anti-inflammatory medicines.

•Continue work to improve the uptake for cervical screening.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice

10 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected Upwell Health Centre on 10 March 2015 as part of our comprehensive inspection programme. Upwell Health Centre is located in a building which is shared with a separate pharmacy and dentist and serves a population of approximately 9400. The overall rating for this practice is good. We found the practice was good in each of the domains safe, effective, caring, responsive and well led. We found the practice provided good care to older patients, patients with long term conditions, patients in vulnerable circumstances, families, children and young patients, working age patients and patients experiencing poor mental health. Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Staff took account of changes in national guidance when planning patient care.
  • Staff had access to training to update their skills.
  • Practice staff provided proactive and tailored services to vulnerable patients
  • The practice had a robust governance structure in place with a designated quality lead, alongside a range of different regular meetings for staff.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was a clear leadership structure and staff felt supported by management. Three members of staff had been developed and promoted internally to lead role positions.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Improve the arrangements for the security of blanks prescription forms
  • Improve the security of the storage of vaccines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice