23 June 2023 and 19 October 2023
During an inspection looking at part of the service
We carried out an announced focused inspection at Hilltops Medical Centre on 23 June 2023 and 19 October 2023. Overall, the practice is rated as requires improvement.
The ratings for each key question are:
Safe - requires improvement
Effective - good
Caring – not inspected, the rating of good is carried forward from our previous inspection
Responsive - requires improvement
Well-led – good
Following our previous inspection on 3 August 2021, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hilltops Medical Centre on our website at www.cqc.org.uk.
Why we carried out this inspection
We inspected Hilltops Medical Centre as part of our regulatory functions under the Health and Social Care Act 2008. We carried out this inspection in response to risk and to follow-up on the areas identified at our last inspection where the provider should make improvements.
We looked at the safe, effective, responsive and well-led key questions for this inspection.
There was an unavoidable delay between inspection dates that did not have any negative impact on the inspection findings.
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 was with consent from the provider and in line with all data protection and information governance requirements.
This included:
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conducting staff interviews using video conferencing facilities
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completing clinical searches and reviewing patient records on the practice’s patient records system to identify issues and clarify actions taken by the provider
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requesting evidence from the provider
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a site visit to Hilltops Medical Centre
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requesting and reviewing feedback from staff and patients who work at or use the service.
Our findings
We based our judgement of the quality of care at this service on a combination of:
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what we found when we inspected
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information from our ongoing monitoring of data about services and
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information from the provider, patients, the public and other organisations.
We found that:
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The provider had made improvements to areas we identified as needing improvement on our first visit in June, however these were not completed in full in all cases.
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The practice had systems and processes to keep people safe and safeguarded from abuse, in most cases.
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The practice’s systems to assess, monitor and manage risks to patient safety were not always effective.
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Appropriate standards of cleanliness and hygiene were met.
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The practice had effective systems for the appropriate and safe use of medicines, including medicines optimisation.
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Patients received effective care and treatment that met their needs.
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Staff worked together and with other organisations to deliver care and treatment.
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Staff supported patients to live healthier lives.
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The practice organised and delivered services to meet patients’ needs.
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People felt they were not always able to access care and treatment in a timely way.
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The practice had a culture which drove high quality sustainable care.
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The practice used data and information to support decision making.
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The practice involved the public, staff and external partners to sustain high quality and sustainable care.
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There were systems and processes for learning, continuous improvement and innovation.
We found 1 breach of regulation. The provider must:
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Provide care and treatment in a safe way for service users.
More detail is contained in the requirement notice section at the end of this report.
We also found the following areas for improvement where the provider should:
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Continue to monitor and improve cervical screening and childhood immunisation uptake.
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Continue to embed the system to ensure continuous learning from complaints over time and information about the Parliamentary and Health Services Ombudsman in included in all complaint final response letters.
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Continue to monitor patient experience and access and take action to improve performance in relation to National GP Patient Survey data.
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