All inspections: Four Acre Health Centre

We carried out an announced comprehensive inspection at Four Acre Health Centre on 16, 21 November and 9 December 2022. Overall, the practice is rated as requires improvement.

Safe - good

Effective – good

Caring - good

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection on 7, 8, 9 and 16 March 2022 the practice was rated inadequate overall and for key questions safe and well-led. Effective and responsive were rated as requires improvement and caring was rated as good.

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

Why we carried out this inspection

We carried out this inspection to follow up concerns identified from our last inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

Conducting staff interviews using video conferencing.
Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
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 found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
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.
Patients reported difficulty accessing the practice by telephone and reported less satisfaction making an appointment.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Further work was required to embed the governance and oversight of risk into every day practice.

We found one breach of regulations. The provider must:

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

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

Take action to improve feedback from patients.
Continue to improve the uptake of cervical cancer screening and childhood immunisations.

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

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.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

We carried out an announced inspection at Four Acre Health Centre on 7, 8, 9 and 16 March 2022. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective – requires improvement

Caring - good

Responsive – requires improvement

Well-led - inadequate

Following our previous inspection on 2 and 7 September 2021, the practice was rated inadequate for being safe, effective and well-led and requires improvement for being caring and responsive. The practice was placed into special measures.

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

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in the area. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

Why we carried out this inspection

This was a comprehensive inspection to follow up on concerns identified from the last inspection.

How we carried out the inspection/review

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
Staff questionnaires

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 the practice as inadequate for providing safe services. This is because:

We found concerns related to the prescribing of controlled drugs which were re-issued to patients in the asence of a review.
Recruitment was not always carried out according to Schedule 3 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The provider lacked oversight of risks relating to the premises.
Not all staff had access to the electronic incident reporting system and the provider could not evidence all incidents reported in the logbook were investigated and resolved.

However,

The provider had carried out comprehensive medicine reviews of patients prescribed regular repeat medicines.
We saw improvement in safeguarding processes and appropriate safeguarding children training for non-clinical staff had been completed.
Blank prescriptions were kept secure.

We rated the provider requires improvement for providing effective services. This is because:

The provider was not always able to demonstrate the competence of some staff in their role reviewing patients.
Staff had not received appraisals since February 2020.

We rated the provider good for providing caring services.

The provider had made improvements to processes and procedures to improve patient care.

We rated the provider requires improvement for providing responsive services.

The system for managing and responding to complaints had not changed since our last inspection. The provider could not demonstrate a consistent approach to managing and learning from complaints.

We rated the provider inadequate for providing well-led services.

It was unclear which roles took responsibility for the day to day management of the practice.
The provider had not addressed all the concerns identified from our last inspection and we found other issues in relation to risk management and lack of oversight for the governance arrangements at the practice.

We found three breaches of regulations. The provider must:

Ensure care and treatment is provided in a safe way to patients.
Ensure all premises and equipment used by the service provider is fit for use.
Establish effective systems to ensure good governance in accordance with the fundamental standards of care.

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

Continue to make improvements for cervical screening and childhood immunisations.
Continue to gather patient feedback to improve services.

This service was placed in special measures in September 2021. Insufficient improvements have been made such that there remains a rating of inadequate for safe and well-led. 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 six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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

We carried out an announced comprehensive inspection at Four Acre Health Centre on 7 September 2021 and the practice was rated as inadequate overall and placed into special measures.

This focused inspection was to check compliance with the warning notice issued in October 2021 for a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12, Safe care and treatment. As this inspection was to check compliance with the warning notice, the ratings from the previous inspection in September 2021 have not been changed.

During our inspection on 7 September 2021, we found safe care and treatment was not provided in a safe way to patients.

This was because:

Medicine reviews did not contain relevant information and required blood tests for some patients were overdue.
We found concerns relating to the required monitoring of patients prescribed certain medicines.

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.

At this inspection we found arrangements relating to the warning notice for safe care and treatment had been met.

We found that:

The provider was supported by NHS St Helens Clinical Commissioning Group (CCG) and Primary care network to support the practice with the improvement plan.
Patients had been contacted to arrange review of long-term conditions and medication reviews.
Medication reviews contained the relevant information.

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

We carried out an announced inspection at Four Acre Health Centre on 2 and 7 September 2021. Overall, the practice is rated as Inadequate.

Safe – Inadequate

Effective – Inadequate

Caring – Requires Improvement

Responsive – Requires Improvement

Well-led - Inadequate

Following our previous inspection on 5 March 2020, the practice was rated Requires improvement overall and for key questions safe, effective, responsive, well led and good for caring. We issued six requirement notices for Regulation 12 HSCA (RA) Regulation 2014 Safe care and treatment, Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment, Regulation 16 HSCA (RA) Regulations 2014 Receiving and acting on complaints, Regulation 17 HSCA ) Regulations 2014 Good governance, Regulation 18 HSCA (RA) Regulations 2014 Staffing and Regulations 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on the six requirement notices served following our last inspection relating to : Regulation 12 HSCA (RA) Regulation 2014 Safe care and treatment, Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment, Regulation 16 HSCA (RA) Regulations 2014 Receiving and acting on complaints, Regulation 17 HSCA ) Regulations 2014 Good governance, Regulation 18 HSCA (RA) Regulations 2014 Staffing and Regulations 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.

We also reviewed areas where the previous inspection identified that the provider should make an improvement by:

Improve the identification of carers to enable this group of patients to access the care and support they need.
De-clutter consultation rooms to ensure all surfaces can be easily cleaned and continue to replace and improve the fixtures and fittings in line with best practice guidance and, improve security for the back-offices and consultations rooms.
Take steps to complete their own patient survey.
Consider an exclusion zone to improve confidentiality at the front desk.
Take steps to inform staff about the Freedom to Speak Up initiative.

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
Feedback from patients
A short site visit
Staff questionnaires

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 and inadequate for all population groups.

We found that:

Some areas identified as requiring improvement at our last inspection had not been addressed.
We found issues relating to the required monitoring of patients prescribed certain medicines.
Medicine reviews did not contain relevant information and required blood tests for some patients were overdue.
Blank prescriptions were not kept secure.
Non-clinical staff did not have the appropriate safeguarding training.
Leaders did not demonstrate a full understanding of the how to deliver high quality services throughout the practice.
Systems did not support learning from information provided to the service, for example audits, incidents and complaints.
There were gaps in systems and processes to assess, monitor, mitigate risks and provide clinical governance.
Communication systems and the organisational culture needed to improve.

However:

The service had effectively promoted public health initiatives for cervical screening.
Staff had completed training in several key safety topics, for example, sepsis, fire safety and chaperone training.

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 to ensure good governance in accordance with the fundamental standards of care.

The provider should:

Consider refresher support for staff following long periods of absence.
Consider updating customer care training for reception staff.
Consider an external impartial freedom to speak up guardian.

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.

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

We carried out an announced inspection at Four Acre Health Centre on 5 March 2020.

Following our review of the information available to us, including information provided by the practice, we carried out a comprehensive inspection on the following key questions: Safe, Effective, Responsive, Caring and Well-led.

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 safe services because:

Safeguarding policies did not provide staff with the information required to enable them to deal with all kinds of abuse in particular: female genital mutilation (FGM) and radicalisation (PREVENT); assurance could not be provided that staff had completed the required level of safeguarding training; recruitment and selection vetting did not include sufficient checks to ensure all staff were fit and proper to work with vulnerable people.
Required health and safety checks had not been completed.
There was limited evidence of shared learning from significant events.
Systems for managing staff needed to be strengthened, the immunisation status of staff had not been checked in-line with best practice guidance and staff had not completed training in several key safety topics for example, sepsis; fire safety and chaperone training.
Blank prescriptions were not held securely.

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

Systems to ensure care and treatment was in line with best practice guidance needed to be strengthened.
The processes in place to promote public health initiatives such as cervical screening were not effective
Staff management systems were not robust or embedded and the practice could not demonstrate that all the relevant training had been provided to and completed by clinical and operational staff.
The practice had not initiated a clinical audit time-table.

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

Patients did not have ready access to a complaints policy;
The complaints policy provided inaccurate information;
The provider did not have oversight of all complaints because informal comments and concerns were not logged.

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

Leaders did not demonstrate a full understanding of the how to deliver high quality services throughout the practice.
The practice was not supported by a clear vision and strategy.
Comprehensive audit plans to review clinical and operational outcomes were not in place.
Systems did not support learning from information provided to the service for example audits; incidents and complaints.
Communication systems needed to improve.

These findings affected all population groups so we rated all population groups as r equires improvement .

We rated the practice as good for providing caring services because:

Feedback from patients was consistently positive and was in keeping with local and national averages.
Staff dealt with patients with kindness and respect.

The areas where the provider must make improvements are:

Ensure care and treatment of patients is provided in a safe way to patients.
Ensure patients are protected from abuse and improper treatment.
Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to carrying on of the regulated activity.
Ensure all premises and equipment used by the service is fit for use.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

Improve the identification of carers to enable this group of patients to access the care and support they need.
De-clutter consultation rooms to ensure all surfaces can be easily cleaned and continue to replace and improve the fixtures and fittings in line with best practice guidance and, improve security for the back-offices and consultations rooms.
Take steps to complete their own patient survey.
Consider an exclusion zone to improve confidentiality at the front desk.
Take steps to inform staff about the Freedom to Speak Up initiative.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at this practice on the 24th March 2015 and at this time the practice was rated as good.

However, breaches of a legal requirement were also found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On the 30th June 2016 we carried out a focused review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This review was carried out to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in March 2015.

This report covers our findings in relation to those requirements and areas considered for improvement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Four Acre Health Centre on our website at www.cqc.org.uk.

The findings of this review were as follows:

The practice had addressed the issues identified during the previous inspection.
Appropriate recruitment checks had been carried out for staff and the practice had updated their recruitment policy to include all required checks for newly employed staff. The practice had undertaken Disclosure and Barring Service (DBS) checks for staff members.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Four Acre Health Centre.

We undertook a comprehensive inspection on 24th March 2015. We spoke with patients, staff and the practice management team.

Overall, the practice was rated as Good. A caring, effective, responsive and well- led service was provided that met the needs of the population it served. However, improvements were needed to demonstrate the practice was recruiting staff safely.

Our key findings were as follows:

There were systems in place to protect patients from avoidable harm, such as from the risks associated with medicines and infection control. However, improvements were needed to the recruitment of staff as the recruitment records did not demonstrate that all necessary checks were undertaken to demonstrate suitability for their roles.

Patients care needs were assessed and care and treatment was being considered in line with best practice national guidelines. Staff were proactive in promoting good health and referrals were made to other agencies to ensure patients received the treatments they needed.

Feedback from patients showed they were very happy with the care given by all staff. They felt listened to, treated with dignity and respect and involved in decision making around their care and treatment.

The practice planned its services to meet the differing needs of patients. The practice encouraged patients to give their views about the services offered and made changes as a consequence.

There was a clear leadership structure in place. Quality and performance were monitored, risks were identified and managed.

We saw an area of outstanding practice:-

The practice had researched the support available in the community for patients experiencing poor mental health and as a consequence had set up a mental health advocacy project. This was a weekly two hour clinic that clinical staff could refer patients to. The main purpose being to signpost patients to appropriate community support services and to support patients during the gap of being referred to a specialist support service and waiting to be seen.

There were areas of practice where the provider needs to make improvements

Importantly, the provider must:

Take action to ensure its recruitment policy, procedures and arrangements are improved to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held.

The provider should:

Implement a more robust system for identifying and managing health and safety risks within the premises.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Four Acre Health Centre

All Inspections

16, 21 and 9 December 2022

During a routine inspection

7, 8 , 9 and 16 March 2022

During a routine inspection

15 November 2021

During an inspection looking at part of the service

7 September 2021

During a routine inspection

5th March 2020

During a routine inspection

30/06/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

24th March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)