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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 carried out on 11 Sept 2019

During a routine inspection

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 carried out on 26 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sunnyhill Healthcare C.I.C on 26/10/2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.

  • Staff were aware of their responsibilities in helping to safeguard and protect patients and had undertaken specific training appropriate to their role, to support this.
  • 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.
  • They worked well with multidisciplinary teams, including community and social services to plan and implement care for their patients.
  • Results from the National Patient Survey showed the practice performed above the local CCG and national averages.
  • Exception reporting for the practice was below the local and national averages.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice held regular staff and clinical meetings where learning was shared from significant events and complaints.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice offered extended hours appointments.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice hosted a number of community services which enabled patients to access services nearer home.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

There was one area where the practice should make improvements:

  • Ensure clinical audit processes effectively assess, monitor and improve the quality and safety of services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 10 February 2014

During a routine inspection

We found the surgery to be very welcoming with friendly, approachable staff. The practice was based on one floor with a waiting room and consultation rooms. Information was clearly displayed throughout the surgery for people using the service, including health promotion, information about the practice, the variety of services available, as well as how to raise any concerns if someone was not happy with the service provided.

During our visit we met with the practice manager and one of the GP partners. We spoke with three people, one relative and three members of staff. We observed reception staff offering people a choice of suitable dates and times for appointments. People we spoke with told us they were happy with the care and treatment they received. One person said, “I am very happy here." Another said, “I get treated with respect when I am seen and listened to.”

We also spoke with staff who said they felt well supported by the provider. One member of staff said, "It's a fantastic team. I really enjoy working here. I've done some good training since I started." We looked at the recruitment processes for staff and saw evidence of effective recruitment checks made before staff commenced employment. We saw that staff received training that was appropriate for their role.

We reviewed the records in respect of complaints and saw that the provider dealt with these in accordance with its policy. People were asked for their views, and we found that these were acted upon.