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Halcyon Medical Limited Good Also known as Halcyon Medical Practice

We are carrying out checks at Halcyon Medical Limited. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 11 April 2018

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

Inspection areas

Safe

Requires improvement

Updated 11 April 2018

Effective

Good

Updated 11 April 2018

Caring

Good

Updated 11 April 2018

Responsive

Good

Updated 11 April 2018

Well-led

Good

Updated 11 April 2018

Checks on specific services

Older people

Good

Updated 11 April 2018

People with long term conditions

Good

Updated 11 April 2018

Families, children and young people

Requires improvement

Updated 11 April 2018

Working age people (including those recently retired and students)

Good

Updated 11 April 2018

People whose circumstances may make them vulnerable

Good

Updated 11 April 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 11 April 2018