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Sunnyhill Healthcare C.I.C Inadequate Also known as Arlesey Medical Centre

We are carrying out a review of quality at Sunnyhill Healthcare C.I.C. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 29 October 2019

We carried out an announced comprehensive inspection at Sunnyhill healthcare C.I.C. on 11 September 2019 in response to an annual regulatory review.

At the last inspection in March 2017 we rated the practice as good overall.

Our judgement of the quality of care at this service is based 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.


The practice is rated as inadequate overall.

The practice is rated as inadequate in providing safe services because:

  • The systems supporting infection prevention and control were lacking. There were areas of the building that showed disrepair and areas that required deep cleaning.
  • The practice had not completed a health and safety, security or legionella risk assessment. Shortly after the inspection, we received evidence that a health and safety risk assessment had been completed and an associated action plan developed.
  • There was no learning taken or shared from significant events or an analysis of trends.
  • The recording of staff immunisation and vaccination was incomplete and did not have self-certification from staff.
  • There was no evidence of actions taken from patient medicine and safety alerts.
  • Patient Group Directions that allowed non-prescribers to give vaccines were not signed by an appropriate person.
  • Emergency medicines were not easily accessible.

The practice is rated as requires improvement for providing effective services because:

  • The practice had not reached public health targets for the percentage of eligible patients receiving cervical screening.
  • The practice had not completed any quality improvement activity, such as two-cycle clinical audits.
  • There was limited oversight of prescribers or formal audit of their practice.
  • The system for appraisal was informal and documentation was not detailed.
  • The system for following up children who may be at risk was disjointed and there was no fail-safe system in place.

The practice is rated as good for providing caring services because:

  • Patients told us staff were caring and compassionate and worked hard to meet their needs.
  • The practice had identified 1% of the practice population as carers and offered appropriate support.

The practice is rated as requires improvement for providing responsive service because:

  • The practice did not appropriately respond to complaints received and there were no analysis of trends, themes or identification of potential significant events from complaints.
  • There was no clear learning identified or shared from complaints.
  • Information of how to escalate concerns to the Parliamentary and Heath Service ombudsman was not available to patients.
  • There was no analysis of themes from patient feedback.
  • GP patient survey results regarding access were in line with local and national averages and patients told us they could make appointments when they needed.

The practice is rated as inadequate for providing well-led services because:

  • There were ineffective governance arrangements in place.
  • There were ineffective processes to manage risk, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • The practice did not always act upon complaints received appropriately, there was a lack of analysis of themes, trends or identification of potential significant events from complaints received or from patient feedback. Learning was not identified and shared with the wider practice team.
  • There was no action plan in place for service development or analysis of challenges the practice faced.
  • There was no process for organisational audit or risk assessment.

The areas where the provider should make improvements are:

  • Improve cervical screening uptake.
  • Improve the identification and support for carers.

There were areas where the provider must make improvements as they are in breach of regulation 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.

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 BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Effective

Requires improvement

Responsive

Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement