The Care Quality Commission
  • Doctor
  • GP practice

Culcheth Medical Centre

Overall: Good read more about inspection ratings

Jackson Avenue, Culcheth, Warrington, Cheshire, WA3 4DZ (01925) 765101

Provided and run by:
Culcheth Medical Centre

Important: The provider of this service changed. See old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Culcheth Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Culcheth Medical Centre, you can give feedback on this service.

20 May 2021

During an inspection looking at part of the service

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

29/05/2019

During a routine inspection

We carried out an announced comprehensive inspection at Culcheth Medical Centre on 29 May 2019 as part of our inspection programme.

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 rated the practice as requires improvement for providing safe services because:

  • The systems for ensuring staff were appropriately authorised to administer medicines to patients and for monitoring uncollected prescriptions was not robust.

  • The systems for identifying and reviewing children subject to safeguarding concerns and vulnerable adults was not robust.

We rated the practice as requires improvement for providing well-led services because:

  • The systems for managing complaints and significant events did not ensure the learning and actions were fully documented so that they could be shared effectively with staff.

  • The provider had not notified CQC of a patient death that may have been related to the regulated activity or how it was provided.

We rated the practice as good for providing caring, effective and responsive services because:

  • The practice reviewed the effectiveness and appropriateness of the care it provided.

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We rated the population groups as good.

The area where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.

  • 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

  • Ensure specified information is referred to CQC in accordance with the (Registration) Regulations 2009.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Introduce a system to monitor two-week rule referrals to ensure patients receive the clinical care they are referred for.

  • Formalise the system for reviewing the practise of clinical staff to ensure consultations, referrals and prescribing are appropriate.

  • Review the system to monitor safety alerts to ensure it is effective.

  • Put a warning on the plug of the vaccine fridge so that the electricity supply is not interrupted and secure the cords of window blinds so that they do not present a hazard.

  • An annual review of significant events should be undertaken in addition to the quarterly reviews.

  • A designated clinical lead for complaints to be put in place.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care