Clayhill Medical Practice

We carried out a comprehensive inspection at Clayhill Medical Practice on 12 February 2019. The practice was rated inadequate overall. Specifically, they were rated as inadequate for safe, effective and well-led, and requires improvement for caring and responsive. The practice was placed into special measures for a period of six months.

In particular, on 12 February 2019, we found the following areas of concern:

• Good governance systems were not established in accordance with the fundamental standards of care.
• The provider failed to operate an effective system of leadership and governance at the practice.
• Systems for ensuring staff received appropriate and up to date training were ineffective.
• Systems and processes relating to temporary staff were lacking.
• There was no evidence available of recruitment processes.
• Risk assessments and monitoring checks were either inconsistent, incomplete, or had not been completed at all.
• The system for the monitoring and security of prescription stationery was ineffective.
• Medicines requiring storage in the refrigerator were not being monitored effectively.
• The systems for monitoring and maintaining equipment and medicines for use in an emergency, were lacking or non-existent.
• There was no consistency or coordination in several areas of practice systems and governance including: performance management; patient treatment; handling of patient safety alerts; complaints; significant events investigation, learning and dissemination.
• The provider was also carrying out the regulated activity of maternity and midwifery without registration.

As a result of our findings at this inspection we took enforcement action against the provider and issued them with a warning notice for improvement.

We carried out a focused inspection at Clayhill Medical Practice on 2 July 2019 to check whether the practice had made the improvements in the warning notice. We found that improvements had been made and the provider had met most of the requirements of the warning notice. However, there were still breaches of regulation and further breaches were identified.

We carried out an announced comprehensive inspection at Clayhill Medical Practice on 17 September 2019. This was to follow up on breaches of regulation and to review whether the practice had made sufficient improvement to take it out of special measures.

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 requires improvement overall.

We rated the practice as inadequate for the population group people with long-term conditions. This was because:

• Performance data relating to patients with diabetes was lower than local and national averages.
• Unverified performance data relating to patients with diabetes was lower than the preceding year.

We rated the practice as requires improvement for providing safe, caring and well led services, and for the following population groups within effective: families, children and young people and working age people. This made the practice requires improvement for providing effective services. This was because:

• There was neither a disclosure and barring scheme (DBS) check or risk assessment completed for two new members of staff, who were working without direct supervision and had access to patients.
• Some GP survey data was below local and national averages and the practice had no plan to address this.
• The practice was unable to show that it monitored the process for obtaining consent to care and treatment.
• Some clinical performance data was below local and national averages.
• Some staff had not received an annual appraisal.

We rated the practice as good for providing responsive services because:

• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• Leaders were able to show that they had the capacity and skills to deliver good quality.
• The overall governance arrangements were now more effective.
• The practice now had clear and effective processes for managing risks, issues and performance.
• The practice acted on appropriate and accurate information.
• We saw evidence of systems and processes for learning and improvement.

The areas where the provider must make improvements are:

• 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 to improve performance for patients with long term conditions.
• Continue to improve the uptake of cervical screening and childhood immunisations.
• Implement measures to monitor the consent seeking process.
• Review recruitment processes relating to staff working prior to receipt of a satisfactory DBS check.

Due to the rating of inadequate within the population group of people with long term conditions, this practice remains 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.

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 BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced focused inspection at Clayhill Medical Practice on 2 July 2019. At this inspection we followed up on whether the provider had complied with our warning notice, served following an announced comprehensive inspection at Clayhill Medical Practice on 12 February 2019.

During our inspection on 12 February 2019, we found that the service was not carrying out well-led care. Breaches of regulation were identified. We served a warning notice in respect of good governance at the practice. This was because: they had not established good governance systems in accordance with the fundamental standards of care; they failed to operate an effective system of leadership and governance at the practice; systems for ensuring staff received appropriate and up to date training were ineffective; systems and processes relating to temporary staff were lacking; there was no evidence available of recruitment processes; risk assessments and monitoring checks were either inconsistent, incomplete, or had not been completed at all; the system for the monitoring and security of prescription stationery was ineffective; medicines requiring storage in the refrigerator were not being monitored effectively; the systems for monitoring and maintaining equipment and medicines for use in an emergency, were lacking or non-existent. There was no consistency or coordination in several areas of practice systems and governance including: performance management; patient treatment; handling of patient safety alerts; complaints; significant events investigation, learning and dissemination. The provider was also carrying out the regulated activity of maternity and midwifery without registration.

During our focused inspection on 2 July 2019, we found that improvements had been made and the provider had met most of the requirements of the warning notice. However, there were still breaches of regulation identified and further breaches were identified.

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 found that:

• While the practice had made some improvements since our inspection on 12 February 2019, it had not completely addressed the Warning Notice in relation to significant events learning and dissemination, or the monitoring of medicines requiring storage in the refrigerator.
• There was a period when the refrigerator temperatures exceeded the recommended maximum.
• The practice had applied to add the regulated activity of maternity and midwifery and this was still in progress.
• There was a lack of clinical discussion between both partners and nursing staff.
• There was a system in place to ensure staff received appropriate and up to date training.
• There were systems in place to ensure that temporary staff received adequate induction, support and information to provide safe care and treatment to patients.
• Systems were in place for recruitment, however there was no records of the immunity status of staff, despite this being a requirement in the practice recruitment policy.
• There was a system for the monitoring and security of prescription stationery.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Continue to ensure that the complaints system is consistent throughout the practice.
• Cascade the learning from significant events and complaints to relevant staff in a timely manner.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

During our previous inspection of Clayhill Medical Practice on 13 January 2015, we rated the practice as good.

We carried out an announced comprehensive inspection at Clayhill Medical Practice on 12 February 2019.

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 inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• We did not see evidence of recruitment systems and ongoing checks.
• Systems for infection control and prevention were not effective.
• The practice did not learn and make improvements when things went wrong.
• There were gaps in systems to assess, monitor and manage risks to patient safety.
• Staff did not always have the information they needed to deliver safe care and treatment.
• Some of the systems for medicines management required strengthening.

We rated the practice as inadequate for providing effective services because:

• There was no consistency in the care and treatment of patients between the two GP partners.
• The practice was unable to show that all staff had the skills, knowledge, experience and support to carry out their roles.
• Some performance data including screening data was lower than local and national averages. Some childhood immunisations data was lower than target levels.
• Unverified performance data supplied by the practice showed that performance had deteriorated over the last 11 months, with no capacity to significantly improve this before the end of the March 2019.
• Although there was effective coordination with other organisations to ensure patients had access to the appropriate support; there was insufficient evidence to show this was consistent for both GP partners.

These areas affected all population groups so we rated all population groups as inadequate.

We rated the practice as requires improvement for providing caring and responsive services because:

• GP survey data was lower for three indicators relating to patients’ experience during consultations.
• Due to a lack of communication between the two GP partners which affected the consistency of approaches to care coordination, there was not sufficient assurance that the service always met patients’ needs. GP survey data supported this finding.
• The system for handling complaints was not consistent across the practice, there was limited learning or evidence that learning was shared.
• Patients were positive about their experience of making an appointment.
• Patients felt treated with kindness and respect by staff.

These areas affected all population groups so we rated all population groups as requires improvement for providing responsive services.

We rated the practice as inadequate for providing well-led services because:

• The lack of communication and coordination between the partners affected all governance arrangements and meant that there was no assurance that all patients received the same standard of care and treatment.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We saw little evidence of consistent systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Improve the experience of patients whilst in their consultation.
• Consider how the practice can increase uptake of childhood immunisations and public health screening programmes.

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 BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care