Updated 27 January 2025
Date of Assessment: 9 – 13 May 2025. Clay Cross Medical Centre is a single-handed GP practice and delivers services to 6,613 people under a contract held with NHS England. There is a branch practice in Tupton, Derbyshire. We visited both of these practices as part of our assessment. We carried out an assessment of this service because it had not been assessed since it registered with the CQC in August 2022. The National General Practice Profiles states that the ethnic make-up of the practice area is 97.4% white, 1.2% mixed, 1% Asian, 0.3% black and other 0.2%. The age distribution of the practice population closely mirrors the local and national averages. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had systems in place to investigate significant events and staff were aware of how to raise concerns. Managers investigated incidents thoroughly. However, learning from significant events and complaints was not always shared with staff. Systems for closing down workflow and coding were not effective. Risk assessments had not always been completed to mitigate potential risks. In particular, lack of evidence of staff immunisation to potential health care acquired infections, no pain relief or suction within the practice, storage of oxygen, fire, legionella and gas. Fire safety drills had not been completed at the branch practice. There was not always enough qualified, skilled and experienced staff and non-medical prescribers had not received appropriate clinical supervision. Staff had received regular appraisals but the provider could not evidence that all staff had received training appropriate to their role. Safe recruitment practices were not always followed. Medicines were not always managed well. Following our assessment, the provider sent us action plans of how they were addressing the concerns regarding medicines management. Systems to assess and manage infection prevention and control were in place. Most of the recommended emergency equipment and medicines were available within the practice. People with safeguarding concerns were protected and kept safe.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was mostly based on latest evidence and good practice. The practice were recruiting for a practice nurse to support them in the management of people with diabetes. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. When a person did not have the mental capacity to make decisions, staff involved people important to them.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information in formats that people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care. However, data from the National Patient Survey showed that people’s satisfaction with access to appointments was below the national average.
Most staff were not aware of the practice’s vision and had not been involved in developing it. Governance arrangements needed strengthening. In particular, completion of risk assessments to mitigate potential risks; sharing of learning from incidents and complaints; regular review of policies to ensure they contained up to date information; the completion of clinical audits; and the re-establishment of meetings to support non-clinical members of staff. A culture of continuous improvement with staff given time and resources to try new ideas was not always in place. However, the practice culture was open, transparent and based on listening and trust. Leaders were visible, knowledgeable and supportive, helping staff to develop in their roles. Staff felt supported to give feedback and free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.
We found breaches of regulation in relation to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.