Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Four Acre Health Centre.

We undertook a comprehensive inspection on 24th March 2015. We spoke with patients, staff and the practice management team.

Overall, the practice was rated as Good. A caring, effective, responsive and well- led service was provided that met the needs of the population it served. However, improvements were needed to demonstrate the practice was recruiting staff safely.

Our key findings were as follows:

• There were systems in place to protect patients from avoidable harm, such as from the risks associated with medicines and infection control. However, improvements were needed to the recruitment of staff as the recruitment records did not demonstrate that all necessary checks were undertaken to demonstrate suitability for their roles.

• Patients care needs were assessed and care and treatment was being considered in line with best practice national guidelines. Staff were proactive in promoting good health and referrals were made to other agencies to ensure patients received the treatments they needed.

• Feedback from patients showed they were very happy with the care given by all staff. They felt listened to, treated with dignity and respect and involved in decision making around their care and treatment.   

• The practice planned its services to meet the differing needs of patients. The practice encouraged patients to give their views about the services offered and made changes as a consequence.

• There was a clear leadership structure in place. Quality and performance were monitored, risks were identified and managed.

We saw an area of outstanding practice:-

• The practice had researched the support available in the community for patients experiencing poor mental health and as a consequence had set up a mental health advocacy project. This was a weekly two hour clinic that clinical staff could refer patients to. The main purpose being to signpost patients to appropriate community support services and to support patients during the gap of being referred to a specialist support service and waiting to be seen.

There were areas of practice where the provider needs to make improvements

Importantly, the provider must:

• Take action to ensure its recruitment policy, procedures and arrangements are improved to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held.

The provider should:

• Implement a more robust system for identifying and managing health and safety risks within the premises.

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 this practice on the 24th March 2015 and at this time the practice was rated as good.

However, breaches of a legal requirement were also found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On the 30th June 2016 we carried out a focused review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This review was carried out to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in March 2015.

This report covers our findings in relation to those requirements and areas considered for improvement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Four Acre Health Centre on our website at www.cqc.org.uk.

The findings of this review were as follows:

• The practice had addressed the issues identified during the previous inspection.

• Appropriate recruitment checks had been carried out for staff and the practice had updated their recruitment policy to include all required checks for newly employed staff. The practice had undertaken Disclosure and Barring Service (DBS) checks for staff members.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice