The Care Quality Commission
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  • GP practice

Archived: Halcyon Medical Limited Also known as Halcyon Medical Practice

Overall: Requires improvement read more about inspection ratings

Unit 8, 24 Martineau Place, Birmingham, B2 4UH 0345 245 0780

Provided and run by:
Halcyon Medical Limited

Important: The provider of this service changed. See new profile

All Inspections

4 and 6 July 2022

During an inspection looking at part of the service

We carried out an announced inspection at Halcyon Medical Limited on 4 and 6 July 2022. Overall, the practice is rated as Requires improvement.

Safe - Requires improvement.

Effective - Requires improvement.

Well-led - Requires improvement.

Following our previous inspection on 22 November 2021, the practice was rated Inadequate overall and for the safe and well-led key questions, Requires improvement for providing effective services and Good for providing caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Halcyon Medical Limited on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focussed inspection, carried out within six months of the service being placed into special measures to see if the provider had made the necessary improvements to provide safe and effective care.

  • We inspected safe, effective and well-led key questions.
  • We followed up on ‘shoulds’ identified in previous inspections.
  • Ratings for caring and responsive are carried forward from the previous inspection in November 2021.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

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:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider.

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 have rated this practice as Requires Improvement overall

We found that:

  • Following our previous inspection in November 2021, the provider had improved safeguarding processes to keep patients safe and protected them from avoidable harm.
  • The provider had improved processes to assess, mitigate and manage risk related to the premises.
  • The provider had improved recruitment processes and continued to work with an external company to manage HR and staff performance issues.
  • The practice had reviewed processes to effectively manage staff training information. We found that all staff had completed mandatory training relevant to their role.
  • The provider had reviewed and improved infection prevention and control processes.
  • We found patients did not always receive effective care and treatment that met their needs. The practice had not met four out of five minimum uptake targets for children’s immunisations and was achieving significantly below the national minimum target for cervical cancer screening.
  • The practice had identified 12 new carers since the previous inspection. However, due to the high turnover of patients, their overall number of carers remained low at 36 patients. This was 0.3% of their patient list.
  • The provider had responded appropriately to our warning notice and taken appropriate action to improve quality and safety. We found there had been improvements to governance processes, however, there was a divided culture amongst staff, some staff feeling they were not well supported or that the culture did not promote the delivery of high-quality, person-centred care.

We found two breaches of regulations. 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.

The provider should:

  • Improve arrangements to manage work when staff were absent. This includes re-distribution of clinical and non-clinical workload.
  • Improve access to vaccinations such as shingles and pneumococcal and NHS health checks.
  • Implement systems to vaccinate patients with an underlying medical condition according to the recommended schedule and systems to identify people who misused substances.
  • Improve the uptake of childhood vaccinations and cancer screening.
  • Improve the clinical audit program to demonstrate improvements in quality of care and treatment delivered.
  • Continue to recruit further staff, to allow existing staff time for non-clinical duties such as administration and training.
  • Take action to ensure staff are aware their concerns are listened to and considered.

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

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

5 April 2022

During an inspection looking at part of the service

We carried out an announced inspection at Halcyon Medical Limited on 5 April 2022. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements set out in warning notices we issued to the provider in relation to regulation 12 Safe care and treatment, regulation 17 Good governance and regulation 18 Staffing.

At the last inspection in November 2021 we rated the practice as Inadequate overall. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Halcyon Medical Limited on our website at www.cqc.org.uk

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

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:

  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A shorter 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 provider had complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
  • The provider had reviewed and improved safeguarding systems. Records we checked showed that patient records were coded correctly and safeguarding registers were up to date.
  • The practice had reviewed processes to manage recruitment files. However, this was work in progress and the provider was liaising with an external company to improve recruitment processes further.
  • The practice had reviewed processes to effectively manage staff training information. We found that all staff had completed mandatory training relevant to their role.
  • The provider had reviewed systems to ensure premises risk assessments, as detailed in the warning notice, were being completed and necessary actions being taken.
  • The provider had reviewed and improved infection prevention and control processes.
  • The provider had reviewed it’s processes to ensure the practice held appropriate emergency medicines.
  • The provider had reviewed governance arrangements and implemented new governance processes and structures to enable them to deliver safe and effective care. Where we identified that processes had not been fully embedded, we discussed these with the provider during the inspection. The provider acknowledged further improvements were needed.

Whilst we found no breaches of regulations, the provider should:

  • Continue to review and improve governance systems and processes so that the provider can demonstrate comprehensive assurance systems have been implemented. For example, systems used to manage risks related to the premises and staff recruitment and ongoing management of staff.
  • Continue to review newly implemented processes to be able to demonstrate they are effective and fully embedded. For example, systems to manage prescription security and systems to manage the return of patient records.

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

22 November 2021

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection at Halcyon Medical Limited on 22 November 2021. Overall, the practice is rated as Inadequate.

The ratings for each key question were as follows:

Safe - Inadequate

Effective – Requires Improvement

Caring – Good

Responsive – Good

Well-led – Inadequate

Following our previous inspection on 26 November 2018, 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 Halcyon Medical Limited on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to gain assurances, following concerns that were raised about the safety of the practice.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A 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 did not have clear systems and processes to keep patients safe. We found safeguarding registers lacked information to advise staff of potential concerns.
  • The practice was unable to demonstrate effective leadership. The lack of adequate processes were putting patients at risk and the provider did not have the capability to lead effectively and drive improvement.
  • The management team we spoke with demonstrated a lack of knowledge to ensure effective processes were embedded to drive efficiency, manage risk and ensure safety in the practice.
  • Some emergency medicines were available, but these did not cover all the recommended medicines for general practice. No risk assessments had been completed in the absence of emergency medicines to determine the level of risk if required in an emergency situation.
  • There were ineffective systems in place for processing information relating to new patients including the summarising of new patient notes. We found nine boxes of clinical records awaiting summarising and patient notes waiting return due to patients having left the practice dating back to June 2021.
  • Infection prevention and control was not monitored effectively, with no infection control audit in place and no evidence that staff had completed the relevant training for their role.
  • We found prescription stationery was not kept securely, with blank prescriptions left in printers in consulting rooms and the doors were left unlocked when not in use.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles. We found limited evidence that staff had received regular reviews and appraisals. There was no evidence to demonstrate that staff were given opportunities for learning and development.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to encourage patients to attend immunisation appointments.
  • Continue taking action to improve the uptake of national screening programmes such as cervical screening.
  • Continue to proactively identify carers in order to offer them support where appropriate.

We identified breaches and as result of our inspection, a warning notice was issued under Section 29A of the Health and Social Act 2008 to the provider Dr Matthew Nye in relation to the

regulated activities: Diagnostic and screening procedures, Family planning, Maternity and midwifery services, Surgical procedures and the Treatment of disease, disorder or injury. This was due to the ineffective systems in place for the management of risk, lack of effective systems to enable proactive monitoring of safeguarding registers, inadequate leadership to maintain appropriate governance processes and ensure staff had completed training relevant to their roles.

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

26/11/2018

During an inspection looking at part of the service

We carried out an announced focused inspection on 26 November 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection in March 2018 where breaches of the Health and Social Care Act 2008 were identified. The practice was rated as good overall at the March 2018 inspections, however we had rated the safe key question and the families, children and young people population group as requires improvement. You can read the report from our last comprehensive inspection on 1 March 2018; by selecting the ‘all reports’ link for Halcyon Medical Limited on our website at www.cqc.org.uk. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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 have now rated both the safe key question and the families, children and young people population group as good as the practice has made the improvements required. This means that the practice remains rated as good overall.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The provider had processes in place to gain assurances through relevant checks that staff were competent for their role prior to employment.
  • The provider had reviewed all non clinical staff immunisation status to mitigate risk to both patients and staff.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Staff carrying out the role of chaperoning had completed the appropriate training and received a DBS check.
  • A review of the management of clinical correspondence had been completed and a quality assurance process had been implemented to ensure all letters were dealt with in a timely manner.
  • The practice had commenced on a CCG initiative to improve the accuracy of clinical coding and support the GPs in the management of clinical time.
  • Childhood immunisation rates continued to be lower than the national average, however the practice had implemented processes to encourage patients to attend for immunisation and the practice had seen an increase in uptake in comparison to previous years.
  • The practice carried out annual infection control audits. Areas identified as requiring action were discussed with the landlords for improvement.
  • The practice monitored performance against national screening programmes to improve patient outcomes.
  • With the practice moving to new premises in the near future, patients had been invited to attend an event to discuss the move with the medical director and staff.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

01 March 2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection of January 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

We first inspected, Halcyon Medical Limited on 10 January 2017 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement. The full comprehensive report for the January 2017 inspection can be found by selecting the ‘all reports’ link for Halcyon Medical Limited on our website at www.cqc.org.uk. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.

This inspection was an announced comprehensive inspection, carried out on 1 March 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

  • At the previous inspection the governance arrangements needed strengthening to ensure there was regular monitoring and reviews completed. We found some of the areas previously identified had improved, however we still found gaps in the recruitment procedures. Since the inspection we have received evidence to confirm that the recruitment policy has been reviewed and the practice are in the process of actioning the concerns identified.
  • Non clinical staff were carrying out chaperone duties without an assessment of risk to patients in the absence of the appropriate checks being sought. Since the inspection we have received evidence that risk assessments have been completed and DBS checks had been requested.
  • The practice had assessed patients ‘needs and delivered care in line with current evidence based guidance. Since the previous inspection the practice had adapted the clinical templates to ensure their patients received regular reviews and appropriate treatment.
  • The practice had also introduced focus groups made up of clinical and administration staff for each of the long term conditions. The groups met on a monthly basis to review patients on the clinical registers to ensure patients were receiving the appropriate reviews and care.
  • The practice had implemented a programme of clinical audits to monitor services and demonstrate quality improvement.
  • The practice had policies in place for the management of staff absence; The practice have strengthened these policies and introduced a rota to ensure there was adequate cover in all areas of the practice for the effective delivery of services.
  • The practice had a system in place for the review of urgent clinical correspondence and test results; however we found examples of routine clinical correspondence that had not been actioned since November 2017.
  • The practice had a system in place to identify patients that were no longer living within the local area and who could be removed from the practice list, This allowed the practice to more effectively monitor the low uptake of screening.
  • The practice had implemented a system to monitor performance against childhood vaccinations. One of the practice nurses was the lead clinician in this area. The latest published data for childhood vaccinations showed the practice were below the national average; however data provided by the practice showed improvements.
  • Staff understood their responsibilities to raise concerns, incidents and near misses and the practice reported all events to the local clinical commissioning group through web based incident reporting and risk management software.
  • The practice ensured that care and treatment was delivered according to evidence- based guidelines. They worked with a range of health and care professionals in the delivery of patient care.
  • Results from the GP national patient survey showed high levels of satisfaction in relation to consultations with GPs and nurses.
  • There was a clear leadership structure and staff felt supported by management and there was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Continue to monitor progress against childhood vaccination programme and take action as appropriate to improve uptake.
  • Monitor progress of infection control actions to ensure they are acted on.
  • Assess and monitor performance against national screening programmes and clinical targets to improve outcomes for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Halcyon Medical Limited on 10 January 2016. Overall the practice is rated as requires improvement.

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

  • The practice was proactive in identifying, managing and learning from significant events, incidents and complaints.
  • We saw some evidence that staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver care and treatment. However, the practice was unable to demonstrate timely care planning to ensure appropriate treatment and optimal outcome for patients.

  • The practice could not demonstrate clinical quality improvement as all audits were single cycle audits. Following the inspection the practice had submitted evidence that an osteoporosis audit had been undertaken in 2016 and this is due to be re-audited in the next five years. A miscarriage audit in April 2016 had been carried and discussed. It was agreed by the team that no changes were needed and no re-audit was necessary.

  • Patients could access appointments and services in a way and at a time that suited them. The practice offered appointments with nurses and GPs on Saturdays and Sundays which was ideal for many patients who worked during normal hours.However, some patients commented that they found it difficult to get an appointment with a GP of their choice.

  • There were longer appointments available for patients when needed. The practice operated a duty doctor system and telephone consultation and urgent access appointments for those with serious medical conditions.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. A lift was available for patients who had difficulty with their mobility.
  • Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Some areas of governance were not always effective. For example, systems and processes to support clear patient specific directions (PSDs) for the healthcare assistant to administer specific vaccinations; systems to review and update staff training and recruitment files and to ensure regular monitoring of practice performance and patient outcomes. There were no systems to review performance against childhood vaccinations. Clinical outcomes for childhood vaccination were below expected levels.

  • There was a leadership structure in place however, some staff members including management staff members had been and/or were on long term leave which had an adverse effect on some aspects of the delivery of the service.
  • Information about services and how to complain was available and easy to understand. Annual trend analysis of complaints was carried out and improvements made to the quality of care as a result.

The areas where the provider must make improvement are:

  • Effective systems must be in place for timely care planning to ensure appropriate treatment, welfare and optimal outcomes for patients

  • Healthcare assistants must have a patient specific prescription or direction from a prescriber in place to administer medicines to patients.

  • The practice must strengthen governance systems and processes to proactively monitor performance and improve quality. For example, demonstrate quality improvement through at least two completed clinical audit cycles. Governance processes must be effective in delivering good quality care through appropriate monitoring of childhood vaccinations; professional registration to ensure the process for managing blank prescription forms complied with national guidance. Improve telephone access for patients to services they require and ensure staff files are up to date including staff identification and registration with their professional bodies.

  • The practice must assess and mitigate risks by monitoring staffing levels to ensure appropriate cover is in place to reduce impact on the day to day management of the service.

The areas where the provider should make improvement are

  • Review national GP patient survey results and explore effective ways to improve patient satisfaction.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 August 2014

During a routine inspection

Halcyon Medical Limited in Birmingham is a city centre GP practice with a patient population of 10,210. The practice is located inside a large high street chemist store in a modern, purpose built facility. 

We found the practice was safe, effective, caring, well-led and responsive to patients’ needs. There were systems in place to learn from incidents and respond to safeguarding concerns. The practice was clean. Equipment and medication were fit for purpose and there were appropriate procedures in place to maintain this.

The services provided were designed to promote patients’ health and wellbeing. The practice worked collaboratively with other health providers to ensure this.

Patients were listened to and involved by respectful staff. There were appropriate procedures in place to include patients in their care. 

Appointments were accessible and arrangements were in place to see student patients at the local university. The service acted upon patients’ comments and complaints.

An open culture and management structure meant that staff were engaged, understood their objectives and knew about decisions that affected their work. Risks to patients were managed appropriately.

During our inspection we spoke with patients and read comments they left for us. Patients said they received good care and were very positive about the staff in particular.

Organisations we contacted such as the local Clinical Commissioning Group (CCG), the General Medical Council (GMC) and the local Healthwatch had no concerns about the practice.

The practice population of 10,210 mainly consisted of working age people (city centre professionals) and students (6919 students were registered at the practice). Only 14 patients were aged 75 or over and 1418 patients identified as of Chinese origin.

We found that the practice provided specialised care plans, a named GP and targeted vaccination programmes to effectively care for older people.

The practice responded to the needs of patients with long term conditions. They operated with checked and accurate patient lists and systems of alerts and recalls to ensure patients received their care. Audits were targeted to improve patient care.

Mothers, babies, children and young people were protected because the service had appropriate systems in place to identify and report child protection concerns.

Working age people had their needs considered with the provision of appointments at set times outside of normal working hours. The practice had a number of systems in place to ensure students had their care needs met, including the provision of a surgery on the university campus during term time.

Patients whose circumstances may lead them to have poor access to primary medical services were able to register at the practice through the use of temporary resident registration.

The practice had procedures in place to assist in keeping people with mental health issues and limited understanding safe. These included a counsellor and psychologist service and referral pathways for students reporting low mood or depression.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.