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Edge Hill Health Centre Good

This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating


Updated 2 March 2020

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Effective
  • Responsive
  • Well Led

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

  • Safe
  • Caring

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 received 27 CQC feedback cards about patient care and experience, these cards were given to patients before and during the inspection. Comments made by patients were extremely positive about the services provided and the practice staff. Two negative comments related to a lack of online information for patients and problems with the practice answering their telephones.

We have rated this practice as good overall and good for all population groups.

We found that:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice had a comprehensive programme of quality improvement and used information about care and treatment to make improvements.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
  • Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.
  • The practice actively identified people who may need extra support to live a healthier lifestyle. Staff provided advice and information i.e. leaflets, so people can self-care. This included information in a range of languages to support the local population.
  • The practice understood the needs of its local population and had developed services in response to those needs.
  • In response to concerns raised by members of the public and patients about access to appointments the practice undertook a detailed investigation into the causes. A number of factors were identified as a root cause to these problems and remedial action was taken.
  • There was evidence that complaints were used to drive continuous improvement.
  • Practice leaders had the experience, capacity and skills to deliver the practice strategy and address risks to it. They were knowledgeable about issues and priorities relating to the quality and future of the service.
  • The practice had a culture which drove high quality sustainable care. There were governance structures and systems which were regularly reviewed and there were clear and effective processes for managing risks, issues and performance.
  • The practice engaged with staff and patients to develop services. However, they did not have a Patient Participation Group.

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

  • Consider developing a practice Patient Participation Group which is representative of the local population.
  • Continue to review and monitor the data that falls below the Clinical Commissioning Group (CCG) and national averages.

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


Updated 4 November 2016

The practice is rated as good for the care of people with long-term conditions. The practice held information about the prevalence of specific long term conditions within its patient population such as diabetes, chronic obstructive pulmonary disease (COPD), cardio vascular disease and hypertension. This information was reflected in the services provided, for example, reviews of conditions and treatment, screening programmes and vaccination programmes. Long term conditions were often managed by combining appointments on the same day such as blood tests and medication reviews to reduce the need for multiple appointments. The clinical staff took the lead for different long term conditions and kept up to date in their specialist areas. The practice had multi-disciplinary meetings to discuss the needs of palliative care patients and patients with complex needs. Alerts were added to patient records to notify reception staff about the specific needs of a patient with a long term condition, such as the need for the patient to see a particular clinician to ensure continuity. The practice worked with other agencies and health providers to provide support and access specialist help when needed. The practice referred patients who were over 18 and with long term health conditions to a well-being co-ordinator for support with social issues that were having a detrimental impact upon their lives.

Families, children and young people


Updated 4 November 2016

The practice is rated as good for the care of families, children and young people. Child health surveillance and immunisation clinics were provided. The practice had a reminder system for parents who did not bring children and babies for immunisation, sending these letters out in their native language whenever possible. Appointments for young children were prioritised. Monthly safeguarding meetings were taking place with the health visiting service to review children under 5, which included vulnerable children and those newly registered at the practice. The staff we spoke with had appropriate knowledge about child protection and how to report any concerns. The practice had recently developed links and support for a local children’s Sure Start Centre supporting children and their families across the community.

Older people


Updated 4 November 2016

The practice is rated as good for the care of older people. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. The practice had named GPs for all patients and also specifically for those over the age of 75 years. The practice offered a variety of health checks for older people specifically memory screening and osteoporosis risk assessments. The GPs visited two local older persons care homes on a weekly basis providing continuity to patients, families and carers.

Working age people (including those recently retired and students)


Updated 4 November 2016

The practice is rated as good for the care of working-age people (including those recently retired and students). The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. The practice had an active website as well as noticeboards in reception advertising services to patients.

People experiencing poor mental health (including people with dementia)


Updated 4 November 2016

The practice is rated good for the care of people experiencing poor mental health (including people with dementia). The practice maintained a register of patients receiving support with their mental health. These patients were mostly known by reception staff and we saw they would call patients to remind them an appointment had been booked for them. Patients experiencing poor mental health were offered an annual review. The practice worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. The practice referred patients to appropriate services such as psychiatry and counselling services. The practice had information in the waiting areas about services available for patients with poor mental health. For example, services for patients who may experience depression.

People whose circumstances may make them vulnerable


Updated 4 November 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable. Patients’ electronic records contained alerts for staff regarding patients requiring additional assistance. For example,

if a patient had a learning disability to enable appropriate support to be provided.

The staff we spoke with had appropriate knowledge about adult safeguarding and how to report any concerns.


rvices for carers were publicised and a record was kept of carers to ensure they had access to appropriate services. The practice referred patients to local health and social care services for support, such as drug and alcohol services.