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Inspection Summary


Overall summary & rating

Good

Updated 4 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Edge Hill Health Centre on 21 September 2016. Overall the practice is rated as good.

  • Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and they were fully supported when they did so. Monitoring and reviewing activities enabled staff to understand risks and gave a clear, accurate and current picture of safety. Lessons were learned and communicated widely to support improvement.
  • Safeguarding vulnerable adults, children and young people was given sufficient priority. Staff took a proactive approach to safeguarding and focus on early identification. They took steps to prevent abuse from occurring, responded appropriately to any signs or allegations of abuse and worked effectively with others to implement protection plans.

  • Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately.

  • Patients had good outcomes because they received effective care and treatment that met their needs. Patients care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation. This included during assessment, diagnosis, when people were referred to other services and when managing people’s chronic or long-term conditions, including for people in the last 12 months of their life.

  • Staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. The learning needs of staff were identified and training was put in place to meet these learning needs. Staff were supported to maintain and further develop their professional skills and experience.

  • Patients were positive about the care and treatment they received from the practice. The National GP Patient Survey July 2016 showed that patients’ responses about whether they were treated with respect, compassion and involved in decisions about their care and treatment were overall comparable to local and national averages.

  • Complaints and concerns were taken seriously, responded to in a timely way and listened to. Improvements were made to the quality of care as a result of complaints and concerns.

  • There were systems in place to monitor and improve quality and identify risk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 4 November 2016

The practice is rated as good for providing safe services. There was an effective system in place for reporting and recording significant events. Lessons were shared to make sure action was taken to improve safety in the practice. When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again. The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse. Risks to patients were assessed and well managed. There were infection control policies and procedures in place, staff were aware of their responsibilities in relation to these.

Effective

Good

Updated 4 November 2016

The practice is rated as good for providing effective services. There was a system for identifying the training needs of staff and ensuring that all staff undertook the training they required for their roles. Patients’ needs were assessed and care was planned and delivered in line with current legislation. Staff referred to guidance from the National Institute for Health and Care Excellence (NICE) and used it routinely. Staff worked with other health care teams and there were systems in place to ensure appropriate information was shared. Audits of clinical practice were undertaken. A system for ensuring the regular appraisal of staff was in place. Staff told us they felt supported.

Caring

Good

Updated 4 November 2016

The practice is rated as good for providing caring services. We saw staff treated patients with kindness and respect. Patients spoken with and who returned comment cards were positive about the care they received from the practice. They commented that they were treated with respect and dignity and that staff were caring, supportive and helpful. Patients felt involved in planning and making decisions about their care and treatment. Results from the National GP Patient Survey published July 2016 showed that patient responses regarding care and treatment were comparable to local and national averages.

Responsive

Good

Updated 4 November 2016

The practice is rated good for providing responsive services. Services were planned and delivered to take into account the needs of different patient groups. Access to the service was monitored to ensure it met the needs of patients. Results from the National GP Patient Survey showed that patient responses regarding access to the service were comparable to local and national averages.

The practice had a complaints policy which provided staff with clear guidance about how to handle a complaint.

Well-led

Good

Updated 4 November 2016

The practice is rated good for providing well-led services. There were systems in place to monitor the operation of the service. Staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings. The practice sought feedback from staff and patients, which it acted on. The practice had a focus on continuous learning and improvement.

Checks on specific services

Older people

Good

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.

People with long term conditions

Good

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

Good

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.

Working age people (including those recently retired and students)

Good

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 whose circumstances may make them vulnerable

Good

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.

Se

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.

People experiencing poor mental health (including people with dementia)

Good

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.