Primary Care Centre

We carried out an announced comprehensive at Primary Care Centre on 17 August 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring - inadequate

Responsive – requires improvement

Well-led - inadequate

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was a new registration and the practice had not been inspected previously under this provider.

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 clinical 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 did not have appropriate systems in place for the safe management of medicines. This included an ineffective system for the management of safety alerts, as actions had not been taken to ensure patients were informed of potential risks with certain medicines.
• Patients on high-risk medicines were not being monitored or reviewed regularly. We found examples of alerts on patients records to inform the clinical team that a review was required, however this had not been actioned.
• The process for reviewing patients with long term conditions needed improvement to ensure all patients received the appropriate reviews.
• The process for sharing information with the wider practice team needed to be formalised to ensure all staff were included in the sharing of learning outcomes.
• We found safeguarding registers were not accurate and were unable to gain assurances that there was effective clinical oversight.
• The practice were unable to demonstrate effective supervision of staff carrying out their roles to ensure they were acting within their competencies.
• On reviewing the responses to patients’ complaints, we found examples where the provider had lacked empathy and respect for the patients’ concerns.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Implement processes to improve on screening and immunisation targets.
• Take steps to identify the number of carers registered at the practice.

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 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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care