The Care Quality Commission
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  • GP practice

Archived: Staplehurst Health Centre

Overall: Good read more about inspection ratings

Offens Drive, Staplehurst, Tonbridge, Kent, TN12 0LB (01580) 895823

Provided and run by:
Malling Health (UK) Limited

Important: This service was previously managed by a different provider - see old profile

All Inspections

9 May 2019

During a routine inspection

We carried out an announced comprehensive inspection at Staplehurst Health Centre on 9 May 2019 as part of our inspection programme.

At the last inspection in September 2018 we rated the practice as requires improvement for providing safe, effective and well-led services because:

  • The practice’s systems, processes and practices did not always keep people safe and safeguarded from abuse.
  • Patients were at risk of harm due to medicines management procedures not always being implemented effectively by the practice.
  • Improvements had been made to the way in which significant events were being investigated and recorded. However, the practice was unable to demonstrate that they recorded these appropriately, as well as learned from and made improvements when things went wrong.
  • Patients did not always find the appointment system easy to use and reported that they were not able to access care when they needed it.
  • Governance arrangements were not always effective.

We also found areas where the provider should make improvements:

  • Continue with their plan to improve telephone access.
  • Continue to monitor and improve timely access to the service.

At this inspection, we found that the provider had satisfactorily addressed all of these areas.

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 good overall and good for all population groups.

We found that:

  • The practice’s systems, processes and practices had been improved to ensure they always kept people safe and safeguarded from abuse. The whole team was engaged in reviewing and improving safety and safeguarding systems.
  • Significant improvements had been made to the way in which significant events were being investigated, recorded and monitored.Learning was shared and improvements made when things went wrong.
  • Medicines management procedures were now being implemented effectively by the practice.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Systems and processes to ensure good governance had been significantly improved to ensure they were implemented effectively.

The areas where the provider should make improvements are:

  • Continue to implement and monitor activities to sustain improvements for prescribing performance, where these were lower or higher than local and national averages.
  • Continue to implement and monitor activities to sustain improvement to national GP Survey results, that were below local and national averages.

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

Dr Rosie Bennyworth BS BMedSci MRCGP
Chief Inspector of General Practice

01 Aug 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating November 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Staplehurst Health Centre on 1 August 2018, to follow up on breaches of regulations identified at our inspections in November 2017.

At a previous inspection, November 2017, we rated the practice inadequate for providing safe and well-led services, requires improvement for providing effective and responsive services, and good for caring. The practice was placed into special measures.

We issued a warning notice in respect of some of these issues and found arrangements had improved but not significantly so, when we undertook a follow up inspection of the service on 4 April 2018. A further warning notice was therefore served. The practice was not rated as a consequence of our April inspection. The details of these can be found by selecting the ‘all reports’ link for Staplehurst Health Centre on our website at

We followed up the warning notice as part of this comprehensive inspection.

At this inspection we found:

  • The practice’s systems, processes and practices did not always keep people safe and safeguarded from abuse.
  • Patients were at risk of harm due to medicines management procedures not always being implemented effectively by the practice.
  • Improvements had been made to the way in which significant events were being investigated and recorded. However, the practice was unable to demonstrate that they recorded these appropriately, as well as learned from and made improvements when things went wrong.
  • It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Patients did not always find the appointment system easy to use and reported that they were not able to access care when they needed it.
  • The practice had an action plan to improve quality and was in the process of reviewing the timeliness of the care provided.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice’s complaints system was now being operated effectively and was accessible to all patients.
  • Governance arrangements were not always effective.
  • There was a strong focus on continuous learning and improvement at all levels of the practice.

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.
  • Ensure there are effective systems and procedures to prevent people using the service from being abused.
  • 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:

  • Continue with their plan to improve telephone access.
  • Continue to monitor and improve timely access to the service.

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

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

4 April 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Staplehurst Health Centre on 22 November 2017. Overall the practice was rated as inadequate and was placed into special measures. Practices placed in special measures are inspected again within six months of publication of the last inspection report.

A breach of the legal requirements was found as the practice did not have systems or processes established and operating effectively to assess, monitor and improve the quality and safety of the services provided.

As a result, the provider was not assessing, monitoring and improving the quality and safety of the services provided and mitigating the risks related to the health, safety and welfare of service users and others. Therefore, a Warning Notice was served in relation to Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

  • Regulation 17 Good Governance.

Following the comprehensive inspection, we discussed with the practice what they would do to meet the legal requirements in relation to the breach and how they would comply with the legal requirements, as set out in the Warning Notice.

We undertook this announced focused inspection on the 4 April 2018, to confirm that the practice had carried out their plan to meet the legal requirements, in relation to the breaches in regulations that we identified in our previous inspection on 22 November 2017. The practice was not rated as a consequence of this inspection, as the practice is in special measures. It will be inspected again, with a view to assessing the practice’s rating when the timescale for being placed into special measures has passed.

This report only covers our findings in relation to those requirements. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Staplehurst Health Centre on our website at www.cqc.org.uk

Our key findings were as follows:

  • The system for recording, analysing, acting on and learning from significant events had not significantly improved since our November 2017 inspection.
  • The systems and processes to manage infection prevention and control had improved. However, not all these improvements were being effectively implemented.
  • Systems and processes had improved for the safe management of prescriptions.
  • The practice had made some improvements regarding patient access to services.
  • The arrangements for planning and monitoring the number and mix of staff had improved.

The system for recording, analysing, acting on and learning from complaints had not significantly improved since our November 2017 inspection. Importantly, the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Staplehurst Health Centre on 21 November 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the 21 November 2016 inspection can be found by selecting the ‘all reports’ link for Staplehurst Health Centre on our website at www.cqc.org.uk

This practice is now rated as Inadequate overall.

The key questions 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? - Inadequate

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 – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

We carried out an announced comprehensive inspection at Staplehurst Health Centre on 22 November 2017. We carried out this inspection as part of our inspection programme in order to follow up on breaches of regulations.

At this inspection we found:

  • The practice did not always have clear systems to identify and manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice was not always able to demonstrate that their analysis identified all risks or that their subsequent action and learning was effective.

  • The practice did not always maintain appropriate standards of cleanliness and hygiene.
  • Staff were aware of current evidence based guidance. The practice could demonstrate how they ensured role-specific training and updating for relevant staff.
  • Most patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. However, the care plans for patients with dementia were not complete or personalised.

  • Staff treated patients with compassion, kindness, dignity and respect.

  • Patients told us they were not always able to access care and treatment from the practice within an acceptable timescale for their needs. This aligned with views in the national GP patient survey.

  • There was an active patient participation group and Friends group. They, together with the practice, provided a programme of health education events to improve the health and wellbeing for people living locally as well as those registered at the practice.

  • The practice had a range of governance documents to support the delivery of the strategy and good quality care. However, we found that governance arrangements were not always effectively implemented.

  • The systems and processes for learning and continuous improvement were not always used effectively to identify risks and areas for improvement. Where these had been identified subsequent action was not always timely or effective.

The areas where the provider Must make improvements are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

  • 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.

The areas where the provider should make improvements are:

  • Review safeguarding systems to help ensure staff have access to timely advice and support from a safeguarding lead.

  • Review training for locum staff to help ensure it meets local policy.

  • Continue to implement a plan to review frail and elderly patients to help ensure all their health and social care needs are met.

  • Continue to review confidentiality in the patient waiting area.

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 be the process of preventing the provider from operating the service. This will lead to cancelling their registration or to vary 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 services the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Staplehurst Health Centre on 21 November 2016. Overall the practice is rated as requires improvement.

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

  • The systems for managing and learning from significant events and complaints were not fully embedded in terms of ensuring that they were appropriately recorded, that trends and issues were identified and that appropriate mitigating action was taken.
  • The practice had a system for receiving and taking action on safety alerts although not all medicines alerts were appropriately recorded on this system.

  • Patients said they hadn’t always found it easy to make routine appointments

  • Data from the national GP patient survey showed patients responses were mixed when compared with the national and local averages for several aspects of care.

  • Risk to patients who used services were assessed, and there were effective systems and processes to address these risks with the exception of those relating to significant events and complaints.

  • 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 effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect.
  • Information about services and how to complain was available and easy to understand. However, not all complaints were appropriately responded to in line with the practice timeline within the complaints policy.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Ensure that the system for managing and monitoring significant events and complaints is effective, that reporting and recording systems are accessible and used by all staff and that learning and the identification of trends and issues is prioritised.
  • Ensure there is an effective system for receiving and action on alerts relating to medicines within the practice.

The areas where the provider should make improvement are:

  • Continue to ensure that Disclosure and Barring Service (DBS) checks are obtained for those staff who require them, as per the practices

  • Ensure that responses and action as a result of patient feedback are clearly identified and acted upon, particularly in relation to issues with the telephone system and appointment booking.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice