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Neath Hill Health Centre Good

Inspection Summary

Overall summary & rating


Updated 16 July 2019

We carried out an announced comprehensive inspection of Neath Hill Health Centre on 6 November 2018. The overall rating for the practice was inadequate and the practice was placed into special measures.

We undertook a focused inspection in February 2019 to follow up on the warning notices we issued to the provider in relation to Regulation 17 Good governance. During the inspection in February 2019 we found the provider had made some improvements to address the concerns identified but had failed to fully comply with the warning notice issued.

From the inspection on 6 November 2018, the practice was told they must:

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

In addition, the practice was told they should:

  • Develop a system, based on best practice, for ensuring records are kept to support appropriate dissemination and discussion of safety alerts.
  • Undertake an analysis of incidents and complaints to identify trends, and to monitor and drive improvement.
  • Establish a programme of regular quality improvement activities to monitor and improve standards of care.
  • Continue with efforts to identify and support carers within the practice population.
  • Review systems for supporting patients with poor mental health so improved clinical outcomes can be demonstrated through the Quality and Outcomes Framework.

The full comprehensive reports from the November 2018 and February 2019 inspections can be found by selecting the ‘all reports’ link for Neath Hill Health Centre on our website at .

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection at Neath Hill Health Centre undertaken on 11 June 2019 as part of our inspection programme to follow up on concerns identified at our previous inspections.

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 all population groups.

Our key findings were as follows:

  • The practice had fully complied with the warning notice we issued, having taken the action needed to comply with the legal requirements.
  • The local leaders of the practice received direct support from the provider organisation to ensure that governance systems were effective. An operations manager from the provider organisation was based on site daily to support the practice team, and to drive and monitor improvement.
  • The practice had developed clear systems to manage risk so that safety incidents were less likely to happen.
  • Significant events and complaints were standing items on the regular practice meeting agenda to ensure areas of learning and improvement were shared with all staff. We saw evidence of discussions and records of actions taken in response to significant events and complaints.
  • Systems for ensuring management oversight of staff training had been improved. All staff had received an appraisal since our inspection in November 2018.
  • Policies and procedures had been established to enable the practice to operate safely and effectively. In particular, we reviewed systems for managing recruitment and found improvements had been made to ensure appropriate pre-employment checks.
  • All staff files had been reviewed and updated to ensure records were accurately maintained.
  • The practice was in the process of uploading all policies and procedures onto a new computer software programme. This programme was also being used to receive and record safety alerts, document significant events and record minutes of meetings.
  • The practice had responded to concerns identified in relation to staff immunity status for specific infections. All staff had received blood tests to identify their immunity status. Those requiring further vaccinations had received them and risk assessments had been undertaken as required.
  • The practice’s system for monitoring safety alerts had changed in the weeks leading to our inspection due to the departure of the clinical pharmacist. On the day of our inspection the practice had not formulated an up to date policy for the management of safety alerts or assigned a new lead. Immediately following our inspection, the practice submitted evidence of an up to date policy and assigned lead.
  • There was evidence action had been taken to ensure appropriate records management, including the summarising of new patient records.
  • Staff advised that staffing levels had improved as the practice had successfully recruited an administrator, a secretary and an additional long-term locum GP. Staff were positive about the improvements made and the impact on their working life.
  • The practice had begun a programme of clinical and internal audit to monitor the quality of care and support improvement.

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

  • Continue to liaise with the landlords of the premises to ensure all outstanding required remedial works are completed.
  • Complete the health and safety risk assessment.
  • Monitor the newly developed policy for managing safety alerts to ensure all alerts are actioned and recorded as required. Consider development of a log for monitoring action taken in response to safety alerts.
  • Develop a programme of quality improvement activity.
  • Maintain records of clinical meetings through documented minutes.
  • Train additional chaperones to alleviate pressures on the practice nurse’s time.

I am taking this service out of special measures. This recognises the significant improvements 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

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable