Archived: Clifton House and Nook Group Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Clifton House and Nook Group Practice on 6 June 2017. Overall the practice is rated as inadequate. The practice is rated as inadequate for providing safe, effective and well led services. They are also rated as requires improvement for providing responsive services and good for providing caring services.

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

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, there was a very low number of incidents recorded over the previous year. When things went wrong, reviews and investigations were undertaken. However, the approach to reviewing and investigating causes was insufficient or unclear. There was no evidence that learning was effectively shared across the staff team.

• Although some risks to patients were assessed, they were limited in scope. For example, there was no evidence of an electrical system check being completed within the last five years. The provider could not produce a gas safety certificate for either the premises or for the boiler at the Clifton House site.

• Whilst the practice could confirm that the lead clinician had the required training in safeguarding, we did not see evidence that mandatory training in safeguarding, health and safety, fire safety, basic life support, infection control and information governance had been completed by all staff.

• Recruitment checks were consistently followed, as references and the appropriate identification and pre-employment checks were seen. However, the provider did not issue written contracts of employment in a timely way or maintain an oversight of the medical indemnity cover of the relevant clinical staff.

• The practice had adequate arrangements to respond to major incidents such as a power failure.

• Medicines were not safely managed across the practice. Records were kept of emergency medicines and these were regularly checked to see that they were in date and fit for use. However, we saw that written checks of the emergency oxygen supply and defibrillator were not maintained. Emergency drugs held at the branch surgery were held in a room that could not be locked and was potentially accessible by members of the public. The provider did not have a validated medical grade cool box for the transfer of vaccines between locations and there were no systems to monitor maximum and minimum temperatures whilst the box was in use.

• Clinical staff were unable to identify who the lead for infection prevention and control was.

• Data showed some patient outcomes were low compared to the national average. There was no meaningful audit activity to drive improvements to patient outcomes.
• We observed patients being treated with compassion, dignity and respect. Results from the national GP patient survey aligned with our observations. Vulnerable patients had been identified and could receive same day access to appointments if requested.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, the system for sharing and acting on drug alerts across the practice was not sufficiently monitored.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about services and how to complain was available. However, detailed responses to complaints were not recorded and there was no evidence of learning from complaints being shared across the staff team.

• Governance meetings did occur, however minutes from these meetings were not sufficient to support learning and ongoing review.

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.

• 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.

The areas where the provider should make improvement are:

• Review the arrangements for the sharing of medicine alerts to assure themselves that information has been seen and acted upon.
• Review the approach taken in supporting patients with mental illness, patients on the palliative care register and those patients with a learning disability to ensure they are appropriately reviewed.

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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice