20 September 2023
During an inspection looking at part of the service
We carried out an announced inspection on 20 September 2023. This inspection was conducted to follow up on Warning Notices issued on 9 June 2023. The practice was inspected, but not rated, which means we carried on the rating from the last inspection in May 2023. Overall, this practice is rated inadequate and is in special measures.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Horizon Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out an announced comprehensive inspection at Horizon Health Centre on 25 May 2023. Overall, the practice was rated as inadequate, and the practice was placed into a Special Measures. We found breaches of Regulation 12 and Regulation 17 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued a Warning Notice.
Following our previous inspection on 25 May 2023, the practice was rated inadequate for the safe and well-led key questions and requires improvement for effective, caring and responsive.
We carried out this inspection on 20 September 2023 to follow up breaches of regulation from the previous inspection that resulted in a Warning Notice being issued on 9 June 2023, in line with our inspection priorities. This report covers findings in relation to those requirements and was not rated.
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.
- 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:
- The practice had taken action to implement improvements to address breaches in regulations previously identified in the Warning Notice.
- There was improved oversight to ensure processes were operating effectively. However, some systems were still being embedded within the practice.
- Improvements had been made to address the previous breaches in regulation. However, there were some aspects of safety and governance that required further improvement and embedding.
- The practice was able to demonstrate improvements in the way individual care records were managed. However, further improvements were required in relation to the management of patients with asthma and medicine reviews.
- The practice had taken action to ensure medicines were appropriately authorised before being administered by staff.
- There were appropriate systems and actions in place to improve infection prevention and control.
- Staff had received training in relation to appointment access, including identifying concerns that needed escalating to GPs.
- The practice had taken action to manage backlogs of activity in relation to correspondence received into the practice, coding and appropriate follow up. However, incoming routine correspondence to be coded was taking 2 to 3 weeks to be processed.
- There were clear processes for identifying and addressing when things went wrong, including sharing learning with staff to ensure improvements.
- Non-medical prescribers received supervision and monitoring of their prescribing practice.
- There were improvements to the way 2-week-wait referrals were monitored.
We found breaches of Regulation 12 Safe care and treatment and Regulation 17 governance . The provider must:
- 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.
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