Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hope Citadel Healthcare CIC also known as Hawthorn Medical Centre, on 27 August 2015. The overall rating for the practice was good, although the practice was rated as requires improvement for safety.

The full comprehensive report on the August 2015 inspection can be found by selecting the ‘all reports’ link for Hope Citadel Healthcare CIC on our website at www.cqc.org.uk.

This inspection was an announced desk based inspection carried out on 22 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 27 August 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for safe services, and overall the practice is rated as good.

Our key findings were as follows:

• At our previous inspection we found that the business continuity plan had not been updated since July 2015 and contained details of the primary care trust (PCT) which was replaced by the clinical commissioning groups in 2013. The practice submitted evidence to demonstrate that they had updated the business continuity plan so all information was accurate.

• At the previous inspection we suggested that the practice update their website as there was some out of date information included. The practice website had been amended however, this still referred patients wishing to escalate complaints to the Healthcare Commission which was superseded by the Care Quality Commission (CQC) in 2008. The practice manager told us this would be changed.
• At the previous inspection fire safety checks were not being carried out on a regular basis. We found the last recorded check of the escape routes had been conducted in 2012 and the fire alarms in 2014 and 2015. The practice submitted evidence to demonstrate these checks were now carried out on a monthly basis with the results documented.

There is one area of practice where the provider should make improvement.

The provider should:

• Update the website complaint guidance to remove reference to the healthcare commission.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

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 Hope Citadel Healthcare CIC on 27 August 2015. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of fire safety checks.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a GP and that there was continuity of care, with urgent appointments available the same day. The walk in centre run by the practice in the same building provided GP access if no appointments were available at the practice.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw three areas of outstanding practice:

• The practice had an in-house counselling service with no waiting lists. As part of the counselling service young people had access to the Cardiff Model, where patients were asked to complete a questionnaire prior to having face to face counselling session to engage the patient in solution focussed discussion.
• The practice had a focussed care team. Staff in this team had various backgrounds including social work, general and school nursing and learning disabilities. When a GP had no medical concerns about a patient but was worried about other aspects of their well-being they referred the patient to the focussed care team to help with social issues such as housing and debt.
• There was seven day access to the practice, with appointments being available between 8am and 8pm Monday to Friday.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure all fire safety checks are carried out and recorded at appropriate intervals.

The provider also should:

• Update the business continuity plan so all information is accurate.
• Ensure all information, for example information on the website regarding escalating complaints, is accurate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice