The Acton Health Centre

We carried out an announced inspection at The Acton Health Centre on 13 May 2022. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

The key questions are rated as:

Safe - Requires improvement

Effective - Requires improvement

Well-led - Requires improvement

The practice inherited ratings from the last inspection with the previous provider. The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Acton Health Centre on our website at www.cqc.org.uk.

Why we carried out this inspection

This was a focused inspection. We carried out this inspection as part of our regulatory functions because a new provider took over this practice in June 2020.

At this inspection we covered three key questions:

• Are services safe?
• Are services effective?
• Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

• Conducting staff interviews.
• 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.

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 Requires Improvement overall.

We found:

There was a lack of good governance in some areas.

• Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines and potential missed diagnosis/ coding issues with diabetes, over usage of medicines and medicine used to treat thyroid hormone deficiency.
• Patient treatment was not always regularly reviewed and updated.
• Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations.
• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded, and their use was monitored in line with national guidance.
• Risks to patients were not assessed and well managed in relation to some safety alerts, some emergency medicines, staff vaccination and the monitoring of the repeat prescription box for uncollected prescriptions.
• Some staff had not received safeguarding children, safeguarding adults, sepsis awareness, equality and diversity, chaperone and fire safety training relevant to their role.
• Actions from recent fire and legionella risk assessments were not completed in a timely manner.
• A defibrillator was not correctly stored, and an appropriate poster was not displayed. Some non-clinical staff we spoke with were not sure about the exact location of the defibrillator. It was regularly checked and fit for use.
• The senior GP supervised the prescribing competence of non-medical prescribers. However, these clinical conversations were not formally documented.
• The practice’s uptake of the national screening programme for cervical and bowel cancer screening was below the national average.
• The Patient Participation Group (PPG) was not active.
• The practice carried out repeated clinical audits.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We found three 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.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Maintain written records when the prescribing competence of a non-medical prescriber is clinically reviewed and discussed with them.
• Continue to encourage the patient for cervical and bowel cancer screening uptake.
• Organise sepsis awareness training.
• Take necessary actions to address the Care Quality Commission registration issues.

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