Cleckheaton Group Practice Also known as St John's House

Updated 15 December 2022

Cleckheaton Group Practice (also known as St John’s House) is on Cross Church Street, Cleckheaton, West Yorkshire, BD19 3RQ. The practice provides services to 9,323 patients. It holds a Primary Medical Services (PMS) contract with NHS West Yorkshire Integrated Care Board (ICB).

The practice operates from a purpose-built medical centre located in Cleckheaton town centre. An independent pharmacy is located within the practice and uses the same entrance. There is extensive free public car parking in front of the practice.

The practice operates from 2 levels. The ground floor consists of the reception and waiting area, patient toilets and 7 consultation rooms, which includes a treatment and phlebotomy room. The lower ground floor, accessible by stairs, consists of 3 consultation rooms, 3 administrative offices and a staff room.

The provider is registered with the Care Quality Commission (CQC) to deliver the Regulated Activities of diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures.

The practice is part of a wider network of GP practices which forms the Spen Health and Wellbeing Primary Care Network (PCN) which includes 6 other practices.

The practice team consists of 4 female and 1 male GP partners, all of whom undertake 8 clinical sessions each week. They are supported by a practice nurse, a full-time trainee advanced clinical practitioner, two health care assistants, a phlebotomist and a nurse associate who was on maternity leave at the time of our inspection. The non-clinical team includes a practice manager and business manager, 3 administrators, 3 secretaries and 5 receptionists. The practice had pharmacy support, a paramedic, a social prescriber and a mental health practitioner through the primary care network (PCN).

The practice is open between 8am to 6.30pm Monday to Friday. The practice provides pre-bookable extended access appointments Monday to Friday from 7.30am to 8am. Additional pre-bookable extended access appointments were provided by the GP federation from a practice within their primary care network. We saw appointments were available Monday to Friday from 6.30pm to 8pm and on Saturday from 9am to 5pm.

Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fifth lowest decile (based on 1 to 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 95% White, 3% Asian, 1% Black, 0.5% Mixed and 0.5% Other.

Updated 15 December 2022

We carried out an announced comprehensive inspection at Cleckheaton Group Practice (also known as St John’s House) on 8 and 9 November 2022. Following this inspection, we rated the practice as good overall, and requires improvement for providing safe services.

Safe - requires improvement

Effective – good

Caring - good

Responsive - good

Well-led - good

Why we carried out this inspection

This announced comprehensive inspection was carried out in line with our inspection priorities.

The practice was previously inspected on 18 August 2016 and rated good overall and good for all key lines of enquiry. The full report for the previous inspection can be found by selecting the ‘all inspection reports and timeline’ link for Cleckheaton Group Practice on our website at www.cqc.org.uk.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Reviewing staff questionnaires.
• A shorter site visit.

Our findings

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.

We found that:

• There were gaps in the management of systems and processes to ensure safe recruitment, premises, infection prevention and control and some medicines management.
• Patients could access care and treatment in a timely way.
• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
• There was a system in place for reporting and recording significant events.
• Clinicians reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The clinical and management team demonstrated that they understood the challenges to healthcare provision.

We found one breach of regulation. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Continue to monitor and make improvements to increase the provision of severe mental health (SMI) and learning disability health checks.
• Review the process to formally document the reviews of the consultation notes and prescribing of the staff provided through the primary care network staff.
• Continue to review the outcome of patient feedback to drive improvement in patient experience.
• Continue to recruit patients to join the Patient Participation Group to establish a group representative of the practice population.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services