4 and 6 December 2023
During a routine inspection
We carried out an announced comprehensive inspection at The University Health Centre on 4 and 6 December 2023. Overall, the practice is rated as requires improvement.
Safe – Requires Improvement
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led - Good
Why we carried out this inspection
We carried out this inspection in line with our current inspection priorities.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- Reviewing staff questionnaires.
- 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 found that:
- There were gaps in systems and processes to ensure safe recruitment, premises, medicines management and the management of some patients with long-term conditions.
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- The practice participated in various quality improvement initiatives to drive improvements and patient outcomes.
- The practice was a training practice and had a strong emphasis on education and learning.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The provider demonstrated there was compassionate, inclusive and effective leadership at all levels.
We found one breach of regulation. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
In addition, the provider should:
- Continue to monitor and make improvements to increase the uptake of cancer screening and childhood immunisations.
- Continue to review and improve the identification of carers on the practice register.
- Continue to monitor patient outcomes for access.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care