We carried out an announced comprehensive inspection at East Park Medical Centre on 8 December 2017. The overall rating for the practice was good, with a rating of requires improvement for providing effective services; particularly in relation to the population groups of people with long-term conditions and people experiencing poor mental health (including people with dementia). The full comprehensive report for that inspection can be found by selecting the ‘all reports’ link for East Park Medical Centre on our website at

In addition to the areas which were identified for improvement under the key question of providing effective services relating to that inspection, we also said the practice should make improvements in the following areas:

• Assure themselves that all reception staff who work at the Halton location follow infection prevention and control procedures, and know how to access equipment. For example, keys to the cleaning cupboard and emergency drugs cupboard.
• Review and improve the systems in place so that reviews of patients are completed in accordance with their care and treatment requirements.

This inspection was an announced focused inspection carried out on 7 November 2018. This was to confirm that the practice had improved in the identified areas.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from the provider, patients, public, other organisations and our ongoing monitoring of data about services.

This practice remains rated as good overall and is also now rated as good for providing effective services.

At this inspection we found:

• All staff were aware of, and adhered to, the infection prevention and control procedures.
• Staff knew where keys were kept and how to access the cleaning and emergency drugs cupboard at the Halton site.
• The practice had reviewed their recall systems and the coding of patients. This had resulted in improvements in the numbers of patients who had received reviews of their care and treatment.
• Clear records were kept in relation to the exception reporting of patients and the rationale.
• Since the previous inspection, an additional salaried GP and a specialist mental health nurse had been employed to support service delivery to patients.
• The practice had undertaken their own patient satisfaction survey and had engaged their patient participation group in this process.
• The practice had continued to improve since previous inspections and were actively engaged with the local community.

Whilst we found no breaches of regulations, the provider should:

• Continue to actively recall patients for reviews of their care and treatment and monitor exception reporting.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

This practice is rated as Good overall. (The previous inspection in April 2017 rated the practice as Requires Improvement.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We had previously inspected this practice on 4 April 2017. At that time we found the practice to be rated as Requires Improvement for providing safe, effective, caring, responsive and well-led care. As part of our inspection process, we also look at the quality of care for specific population groups. The issues identified as requiring improvement affected all the population groups.

We subsequently carried out an announced comprehensive inspection at East Park Medical Centre on 8 December 2017. This was to check whether the practice had addressed and actioned the areas of concern which were raised at the 4 April 2017 inspection.

At this inspection we found:

• All practice policies and procedures were embedded and easily accessible. Any updates were cascaded to staff and discussed in meetings. However, at the time of inspection, not all staff at the Halton site followed the procedures when handling specimens.
• There were systems and processes in place to manage risk and health and safety. All actions were completed regarding risk assessments such as fire.
• There was an embedded system in place for actioning and cascading drug safety alerts.
• There was evidence of shared learning and actions being taken as a result of reported indicents. The practice used incident report to drive change as appropriate.
• The practice had procured the services of an outside agency to support them in improving their systems to ensure all patients were coded appropriately. This was used to support improvements relating to the quality and outcomes framework (QOF).
• There were systems in place for the recall and review of patients. However, the practice had acknowledged they had experienced difficulty in ensuring all patients had received their reviews in line with timescales.
• The practice had engaged with Healthwatch regarding a patient survey and they had also recently commissioned their own. They were using the results of these surveys to identify areas for improvement, such as patient access.
• Information was available for patients in languages and formats suitable for the practice population.
• There had been noticeable improvements in the leadership and management of the practice.
• There was a strong commitment towards continuous learning and improvement throughout the practice. There was evidence of a cohesive team approach and staff were positive when talking about the changes that had happened in the practice.
• There was a range of clinical and non-clinical meetings which were all minuted.
• There was evidence of effective engagement with the patient participation group and using the group to support improvements in patient satisfaction.
• The Care Quality Commission registration processes had been completed in relation to the registered manager.

The areas where the provider should make improvements are:

• Assure themselves that all reception staff who work at the Halton location follow infection prevention and control procedures and know how to access equipment. For example, keys to the cleaning cupboard and emergency drugs cupboard.
• Review and improve the systems in place so that reviews of patients are completed in accordance with their care and treatment requirements.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at East Park Medical Centre on 10 August 2016. The findings at that inspection lead to an overall rating of inadequate and the practice was placed in special measures for a period of six months. We also issued two warning notices for breaches in regulations relating to the Health and Social Care Act 2008. The full comprehensive report for that inspection can be found by selecting the ‘all reports’ link for East Park Medical Centre on our website at www.cqc.org.uk.

Following the period of special measures, an announced comprehensive inspection was undertaken on 4 April 2017. During that inspection we found that the practice had taken considerable action relating to the breaches in regulation. However, there remained a breach in Regulation 12 relating to the actioning of drug safety alerts. Overall the practice is now rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• The practice had significantly improved their systems and processes. Policies and procedures had been reviewed and were now easily accessible to all staff via the practice computer system.
• Processes had been introduced regarding risk management, which included fire, infection prevention and control, legionella and the security of the reception desk at the Halton Medical Practice location.
• Staff were aware of the importance of incident reporting. All clinical and non-clinical incidents were now reported and recorded as significant events.
• There was a repeat prescribing policy and system now in place for the recall and review of patients; particularly those who were on medicines which required close monitoring.
• A risk assessment had been undertaken regarding the range of medicines available in GPs bags. It had been decided that none would be kept in the bags, however, the practice had introduced a ‘grab bag’ of medicines GPs could use to take on home visits.
• A comprehensive system had been introduced regarding the security of prescriptions; this included the removal of prescriptions from clinical rooms by staff and stored in locked cabinets overnight
• Since the previous inspection the practice had commenced a programme of clinical audit. We saw evidence where completed audits could demonstrate quality improvement regarding patients’ care and treatment.
• We saw evidence that staff were now up to date with their annual appraisals and mandatory training, including fire and safeguarding at the level appropriate for their individual roles. A revised induction and mentoring process had also been implemented for newly recruited staff. Management of clinical staffing had been strengthened; staff said they were “proud to work for the practice”.
• The practice had reinstated the patient participation group and were effectively engaging with the group, particularly in relation to improving the patient experience.
• The GP partners had invested in a complete refurbishment of the premises; patients and staff commented very positively about the changes.
• Although the practice had introduced a process to monitor safety alerts and identify what actions had been undertaken, it was found that not all drug safety alerts had been actioned between December 2016 and February 2017.

The area where the provider must make an improvement is:

• The provider must assess the risks to the health and safety of patients and do all that is reasonably practicable to mitigate any such risks. They must ensure that all drug safety alerts are acted on accordingly, to minimise any risk to patient safety.

The areas where the provider should make improvements are:

• Complete all remaining actions in relation to the fire risk assessment.
• Undertake any outstanding reviews of care and update care plans for all appropriate patients. For example, those with a long term condition, a complex mental health need or those at risk of an unplanned hospital admission.
• Provide practice and health information in appropriate languages and formats which reflect the patient population.
• Take steps to improve patient access to appointments.
• Complete the CQC registration process in relation to a registered manager.

I am taking this service out of special measures. Although we recognise the significant improvements made to the quality of care provided by the service, the service would further benefit from continued support.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at East Park Medical Centre on 10 August 2016. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because systems and processes were not effective enough to keep them safe. We found areas of concerns in relation to policies, health and safety, fire risk, infection prevention and control and the recall and review of patients.
• Patients were signposted to other services for support as needed, such as alcohol misuse services, memory services and a health trainer who was attached to the practice.
• Staff understood their responsibilities to raise concerns and report incidents, however, not all non-clinical events or ‘near misses’ were reported and recorded as significant events.
• Although the practice cascaded national and regional safety alerts, they did not have a process in place to monitor what actions had been undertaken in respect of those alerts.
• There was little evidence to support whether checks of the medicines within the GPs’ bags were kept. There was no evidence of a risk assessment being undertaken as to what emergency medicines were carried by the GPs.
• Annual appraisals for staff were overdue and it was not clear whether all staff had completed mandatory training, specifically regarding fire safety and safeguarding.
• We saw that due to workload demands, the opportunity to provide an effective and supportive induction and mentoring programme for new nursing staff members was limited.
• Although some audits had been carried out, not all had undergone two completed audit cycles to ensure that improvements made were implemented and monitored for quality improvement.
• Patient survey responses rated the practice below the CCG and national averages for many questions relating to the care and service they received. However, patients’ comments we received as part of the inspection, said they received a good service and were supported, listened to and cared for.
• The practice responded to patient feedback from the NHS Friends and Family Test and had improved access by increasing the number of same day appointments and telephone consultations.

The areas where the provider must make improvements are:

• Ensure there are effective systems in place for assessing and monitoring risks relating to good governance and the safety of staff and patients, which include addressing any identified concerns relating to fire risk and infection prevention and control.
• Ensure all clinical and non-clinical incidents and ‘near misses’ that may affect the health, safety and welfare of people using services are reported, recorded and investigated as significant events.
• Ensure there is a clear and consistent approach to managing policies and procedures and that these are practice specific.
• Ensure there is an effective repeat prescribing policy and a system and protocol in place for the recall and review of patients; particularly those who are on medicines which require close monitoring.
• Review the range of medicines available in GPs bags and undertake a risk assessment to evidence the rationale where some recommended medicines have been omitted.
• Ensure all staff receive appropriate support, including appraisal, training, induction and mentorship relevant to their role.
• Ensure patient outcomes are reviewed and recommendations made to contribute to a programme of continuous quality.
• Improve engagement with the patient participation group and take action where appropriate, based on patient feedback.

The areas where the provider should make improvements are:

• Undertake a risk assessment regarding the security of the reception desk at the Halton Medical Practice location.
• Establish a system to log the date that blank prescriptions are received into the practice.
• Provide practice and health information in appropriate languages and formats which reflect the patient population.

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 population group, 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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice