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Edge Hill Health Centre Good

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


Inspection carried out on 29 January 2020

During an inspection looking at part of the service

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 carried out on 21 September 2016

During a routine inspection

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 carried out on 30, 31 October 2013

During a routine inspection

Patients we spoke with told us that staff had been friendly and helpful. Comments included; "Everything is fine I get on well with the doctor, I'd give the doctors 9 out of 10." Another person said; "They talk everything through with me."

Some patients told us that it was sometimes hard to get an appointment at the practice, especially if they needed a specific appointment time slot.

The practice had up to date child and adult protection policies and procedures in place. This information included contact details for staff to raise concerns with the appropriate agencies.

We saw records were kept of adverse events, accidents or incidents including actions taken. The practice completed audits/reports following significant events or receiving complaints, in order to learn and make improvements as required.