The Health Care Complex

We carried out an announced inspection at The Health Care Complex on 14 June 2022. This is the first time this service has been inspected by the Care Quality Commission (CQC) following its registration as a new provider in March 2020. Overall, the practice is rated as requires improvement.

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Why we carried out this inspection

This was a comprehensive inspection at this location as it had been registered by CQC following a change in service provider.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• 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
• A short site visit
• Conduction interviews with key stakeholders using video conferencing

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 that:

• The practice did not have clear systems and processes to keep patients safe.
• We found the practice did not appropriately maintain their safeguarding registers; the safeguarding policy was not comprehensive.
• Review of staff files showed gaps in recruitment processes.
• The practice had ineffective systems and processes in place to manage and monitor infection control, cleanliness and waste management.
• A full range of recommended emergency medicines was not available and risk assessment to identify and mitigate risks had not been completed.
• The provider did not have an effective process in place to manage Medicines and Healthcare Products Regulatory Agency (MHRA) alerts.
• The leaders at the practice did not have full oversight of the challenges and risks to quality and patient care within the service.
• The practice did not have clear and effective processes for managing all risks, issues and performance.
• The provider did not have a plan in place to develop leadership capacity and skills including planning the future leadership of the practice.
• The practice did not have a plan for continuous learning and improvement.
• The provider did not have an effective Patient Participation Group in place.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure patients are protected from abuse and improper treatment.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

For further information see the requirement notice and enforcement section at the end of this report.

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