Background to this inspection
Updated
23 June 2021
Culcheth Medical Centre is located in Warrington at:
Jackson Avenue
Culcheth
Warrington
Cheshire
WA3 4DZ
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning services, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the Warrington Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 12,400. This is part of a contract held with NHS England.
The practice is part of a wider group of GP practices and is a member of the Warrington Innovation Network.
The National General Practice Profile states that 97% of the practice population is from a white background.
There is a team of five GPs who work at the practice: two partners and three salaried GPs. The practice has a team of the advanced nurse practitioners, four practice nurses and two healthcare assistants. They are supported at the practice by a practice manager, deputy practice manager and a team of reception/administration staff.
Due to the enhanced infection prevention and control measures put in place since the Covid 19 pandemic and in line with the national guidance, most GP appointments were telephone or video consultations.
Extended access is provided two days per week at the practice and locally by the primary care network, where late evening and weekend appointments are available. Out of hours services are provided by Urgent Care 24 (UC24).
Updated
23 June 2021
We carried out an announced inspection at Culcheth Medical Centre on 20 May 2021. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 29 May 2019, the practice was rated Requires Improvement overall and the key questions safe and well-led. Effective, caring and responsive key questions were rated Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Culcheth Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This was a focused inspection to:
- Inspect the key questions of safe, effective and well-led.
- Follow up on breaches of regulation 12, 13, 16 and 17 and areas where the provider should improve as identified in our previous inspection.
The key questions caring and responsive were not inspected and so the ratings of good have been carried forward from the previous inspection.
How we carried out the inspection
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 and telephone
- 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 and reviewing 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 have rated this practice as Good overall and Good for all population groups.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. The systems for ensuring staff were appropriately authorised to administer medicines to patients and for monitoring uncollected prescriptions had been improved. The practice had appropriately notified CQC of significant events that met the criteria. Systems for identifying and reviewing children and vulnerable adults subject to safeguarding concerns had been improved.
- Monitoring of safety alerts, consultations, referrals and prescribing of clinicians had improved since the last inspection and were formally documented.
- Warning signs had been placed on plugs of fridges storing vaccines and window blind cords had all been secured.
- Patients received effective care and treatment that met their needs.
- Improvements had been made to the management of complaints, there was a clinical lead in place and they were discussed in various meetings with outcomes and actions disseminated appropriately.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. There had been improvements with communications, systems and processes had been strengthened and embedded and there was better oversight of all areas.
Whilst we found no breaches of regulations, the provider should:
- Continue with plans to strengthen the monitoring arrangements for patients prescribed specific medicines that require regular monitoring.
- Complete annual reviews of significant events to identify themes, trends and assess the outcome of action taken.
- Produce a formal audit plan based on local, national and service priorities.
- Continue to review and monitor the clinical performance data that falls below national targets.
- Record all outcomes for complaints and review these to identify themes, trends and actions completed.
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