All inspections: Eastern Avenue Medical Centre

We carried out an announced comprehensive inspection of Eastern Medical Centre on 9 and 10 November 2020. To review the improvements made following the practice’s last inspection on 20 February 2020 where we rated the practice inadequate overall and placed the practice in special measures.

In light of the Covid-19 pandemic, CQC has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices by minimising the time spent on site in the service, during the pandemic, when compared to a traditional inspection. Therefore the inspection on the 9 and 10 November 2020, we based our judgement of the quality of care at this service on a combination of:

What we found when we carried out a remote review of patient records on 9 November 2020 by a GP specialist adviser.
A visit to the location on the 10 November 2020.
Telephone/video conferencing interviews with the practice manager and the partner GPs.
Staff questionnaires.
Information requested from the provider, patients, the public and other organisations.
Information from our ongoing monitoring of data about services.

At this inspection, we have rated the practice as requires improvement overall and as requires improvement for providing safe, effective, responsive and well-led services and good for providing a caring service. We have rated all of the population groups as requires improvement.

This was because: -

We have rated providing an safe service as requires improvement because we found that the practice had responded to the issues raised at the previous inspection regarding safeguarding, medicines management, recruitment, risks to patients, and the management of significant events and safety alerts, and had started to make some improvements in all areas. However, further work still was required to fully implement, embed and then review these systems.

We have rated providing an effective service as requires improvement because although we found the practice had made some improvements, such as in relation to training and systems to ensure patients had received appropriate care and treatment, these had not had time to embed and demonstrate results. In addition, further improvements were required to ensure that all patients’ care and treatment was reviewed and updated regularly.

We have rated providing an responsive service as requires improvement because although we could evidence improvements in the practice’s understanding of the needs of the different patient population groups, the accessible information standards, complaints handling and the response to the patient survey, the practice’s planned actions in response to the patient survey had yet to be implemented.

We have rated providing an well-led service as requires improvement we found the provider had made improvements by reviewing or initiating new policies and systems. However, some of the policies or systems needed to be embedded to further ensure the quality of the service going forward and ensure any changes were sustained.

We have rated providing an caring service as requires good because they have completed an in-house satisfaction survey and have recently commenced an action plan to improve patients’ experience.

The areas where the provider must make improvements are:

Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

Ensure staff have the recommended vaccinations by Public Health England.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

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

We carried out an announced comprehensive inspection at Eastern Avenue Medical Centre 27 February 2019 as part of our inspection programme. At this inspection, we rated the provider as requires improvement for the key questions of safe, effective and well-led, which lead to an overall rating of requires improvement.

At this time breaches of regulatory requirements under regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014 were identified and requirement notices issued to the provider. The reports for all the previous inspections for Eastern Avenue Medical Centre can be found by selecting the ‘all reports’ link for Eastern Avenue Medical Centre on our website at

This inspection was an announced full comprehensive inspection undertaken on 12 & 26 February 2020.

We based our judgement of the quality of care at this service is 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 have rated this practice as inadequate overall.

We rated the practice as requires improvement for effective, caring and responsive services because:

Staff were not consistent in supporting local and national priorities such as tackling obesity or smoking cessation
Limited quality improvement activity had been undertaken
No internal patient satisfaction surveys had been conducted by the practice
There was no evidence that low quality outcomes framework (QOF) scores in some clinical areas led to practice plans for improvement
The practice did not have a clear fail-safe system for childhood vaccinations and cervical screening
The practice could offer continuity of care and flexibility on when care could be accessed
Evening appointments were available with the practice nurse twice a week

We rated the practice as inadequate for safe and well-led services because:

Not all systems for medicines management were monitored correctly
Staff did not always have the appropriate authorisation to allow the administration of medicines
There were gaps in systems to monitor assess and manage risks
Overall governance arrangements were not effective
There was limited evidence of systems for continuous improvement and learning
There was no evidence of clinical oversight and supervision

These areas affected all population groups, so we rated all population groups overall as requires improvement.

The areas where the provider must make improvements are:

Ensure care and treatment is provided in safe way to patients
Ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care

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.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Eastern Avenue Medical Centre on 27 February 2019 as part of our inspection programme for practices rated inadequate in one or more key question at our last inspection of the practice.

We based our judgement of the quality of care at this service is 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 have rated this practice as requires improvement overall, requires improvement for providing safe, effective and well led services and good for providing caring and responsive services.

We rated the practice requires improvement for safe services because

Prescription security was not maintained during working hours.
The practice nurse was not working to a recognised protocol which legally authorised them to administer vitamin B12 injections.
Not all Patient Group Directions (PGDs) in use had been authorised by the provider or the practice manager.
Safety alerts received were disseminated amongst staff but there was little evidence indicating that all relevant staff had read them.

We rated the practice as requires improvement for effective services because

Not all patients on high risk medication had received recent reviews.
Clinical staff did not always use current best practice guidelines when making clinical decisions.

We rated the practice requires improvement for well-led services because

There was no oversight by the provider of the work undertaken by clinical staff employed at the practice.
Meeting minutes showed a key member of clinical staff did not attend clinical meetings at the practice.

We rated the practice good for caring and responsive services because

The practice made use of social prescribing to encourage patients to take ownership (with clinical support) of their health needs.
The practice conducted clinical audits and could show improvement in patient care because of audits.
Patient experiences at the practice were positive, except for occasionally not being able to obtain suitable appointments and the manner of some members of staff.
Complaints were dealt with in line with recognised guidance.
The practice had scored well in some areas of the National GP Patient survey relating to decisions about their care.

We have rated the practice as good for all the responsive population groups and requires improvement for the effective population groups. This means that the population groups are rated as requires improvement overall.

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please refer to the requirement notice section at the end of the report for more detail).

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of Eastern Avenue Medical Centre on 26 June 2018 and found that the practice was in breach of Regulation 12: ‘Safe care and treatment’ of the Health and Social Care Act 2008. In line with the Care Quality Commission’s (CQC) enforcement processes, we issued a warning notice which required Eastern Avenue Medical Centre to comply with the Regulations by 11 August 2018.

The full report of the 26 June 2018 inspection can be found by selecting the ‘all reports’ link for Eastern Avenue Medical Centre on our website at www.cqc.org.uk.

We carried out this announced focused inspection on 9 November 2018 to check whether the practice had addressed the issues in the warning notice and now met the legal requirements. This report covers our findings in relation to those requirements and will not change the current ratings held by the practice.

At the inspection on 9 November 2018 we found that the requirements of the warning notice had been met, except for one area relating to the administration of medicines.

Our key findings were as follows:

Risk assessments had been completed and effective safety systems were in place in relation to fire, health and safety, legionella and infection control.
The practice had purchased a defibrillator, although the checks of the equipment had not been documented.
Patient Specific Directions (PSDs) were in place for the healthcare assistant (HCA), however the GP was signing these as the authorising prescriber after the medicines had been administered to patients, rather than before.

We identified regulations that were not being met and the provider must:

Ensure care and treatment is provided in a safe way to patients.

You can see full details of the regulations not being met at the end of this report.

We also identified an area of practice where the provider should make improvements:

Review the system for ensuring checks of the defibrillator are completed on a regular basis and recorded.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and evidence table for further information.

This practice is rated as Requires improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Requires improvement.

We carried out an announced comprehensive inspection at The Eastern Avenue Medical Centre on 26 June 2018. This inspection was carried under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service. This is the first inspection since the change in legal entity in May 2017.

At this inspection we found:

The practice did not have systems or processes to manage and mitigate some risks specifically those relating to fire safety, health and safety, legionella and infection control.
The practice ensured that care and treatment was delivered according to evidence-based guidelines.
Although significant events were reported, recorded and investigated, learning was not always evident.
The practice encouraged complaints and took them seriously, however not all complaints were responded to as per practice policy.
Performance data for diabetes and cervical screening cytology was below local and national averages.
Most staff had the skills, knowledge and experience to carry out their roles although not all staff had received updated training the practice identified as mandatory.
Staff involved and treated patients with compassion, kindness, dignity and respect.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

Review policies and procedures to reflect practice’s current arrangements.
Take action to acquire a hearing loop for patients who have difficulty hearing.
Take action to improve underperforming areas such as those relating to the GP patient survey, diabetes and cervical cytology screening.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Archived: Eastern Avenue Medical Centre

All Inspections

9 and 10 November 2020

During a routine inspection

12 and 26 February 2020

During a routine inspection

27 February 2019

During a routine inspection

09/11/2018

During an inspection looking at part of the service

26 June 2018

During a routine inspection