Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jordanthorpe Health Centre on 14 and 15 November 2016. The overall rating for the practice was requires improvement with requires improvement in safe and responsive.

We also carried out an unannounced focused responsive inspection on 13 June 2017 following feedback to the Care Quality Commission which raised specific concerns about care and treatment and management of the Darnall Primary Care Centre site. As we did not look at the overall quality of the service we were unable to provide a rating for the service at this inspection. The full comprehensive report from14 and 15 November 2016 and the focused report from 13 June 2017 can be found by selecting the ‘all reports’ link for Jordanthorpe Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 September 2017 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 and 15 November 2016 and 13 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good. Specifically, following the focused inspection we found the practice to be rated good for being safe and responsive.

Our key findings were as follows:

• The provider had implemented a system to review and monitor the risks associated with legionella at all sites.
• The provider had implemented a procedure for sharing communication from secondary care providers.
• The provider had reviewed the action plans implemented following feedback from staff and patients to include sufficient detail to monitor progress particularly with regard to access.
• The provider had implemented a system to ensure blank prescriptions were held securely at all sites and there was a system for tracking their use, including receipt into each site.
• Systems to ensure patient identifiable information was held securely had been reviewed and updated.
• Effective systems to monitor infection prevention and control (IPC) procedures had been implemented.
• We saw evidence administration tasks were actioned in a timely manner and there was a contemporaneous record maintained in patients’ medical records. Staff we spoke with had a good understanding of the process, though the task policy was not sufficiently detailed to promote consistency across the sites.
• The provider had completed a risk assessment of the blinds and type of blind cords used at all sites in line with advisory Department of Health guidance, February 2015. All blinds in patient accessible areas had been made safe. They had either been replaced or had safety mechanisms installed for the cords.
• A plan of continuous clinical audit had been implemented. For example, the diabetic audit was now completed monthly at all sites to ensure appropriate monitoring and recording of a new diagnosis in medical records. The diabetic protocol was discussed and enforced with the doctors at an in-house training event on 13 September 2017 to ensure continual improvement in the management of these patients.

However, there were areas of practice where the provider needs to make improvements.

The provider should:

• Review the task policy to include clear guidelines for all staff at each stage of the process.

• Continue to monitor the access and capacity plan and patient feedback with regard to improving timely access to appointments.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a focused unannounced inspection of this service on 13 June 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned following feedback to the Care Quality Commission which raised specific concerns about care and treatment and management of the practice.

This inspection report relates to the specific areas we reviewed as a result of the feedback received. We inspected the Darnall Primary Care Centre site only. As we did not look at the overall quality of the service we are unable to provide a new rating for the service.

Our key findings across the areas we inspected on 13 June 2017 were as follows:

• There was a system in place for reporting and recording significant events and incidents. We saw evidence significant events and incidents were analysed and action had been taken to prevent the same thing happening again. We saw evidence of learning and communication with staff following incidents.
• A diabetic audit had had been completed and action had been taken to identify patients with a new diagnosis of diabetes to improve patient outcomes.
• Complaints were recorded and handled in an appropriate manner.
• We saw policies were in place to govern records management activity and processes were in place to manage clinical tasks. However, systems to manage administration tasks were not effective. There were shortfalls with regard to security of blank prescription forms, patient identifiable information s and monitoring of infection control procedures.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure blank prescriptions are stored securely as specified in the NHS Protect: Security of Prescription forms guidance 2015.

• Ensure security of patient identifiable information in line with the Data Protection Act 1998.

• Ensure monitoring systems of infection prevention and control procedures are consistently implemented.

• Review and improve the process to manage administration tasks in a timely manner to improve patient outcomes and minimise risk and ensure a complete and contemporaneous record is maintained.

In addition the provider should:

• Review and plan follow up of audits to contribute to continuous quality improvement activity.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jordanthorpe Health Centre (The Clover Group) on 14 and 15 November 2016. Overall the practice is rated Requires Improvement.

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

• There was a system in place for reporting and recording significant events.
• Risks to patients who used services were assessed, however, the systems and processes to control these risks were not implemented well enough to ensure patients were always kept safe.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff told us they had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they did not find it easy to access appointments and improvements to access had not been actioned.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure in place and staff told us they 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.

We saw an area of outstanding practice:

Mulberry Practice was set up in Sheffield in 2002 when it became a dispersal city (key area of accommodation) for asylum seekers. They recognised the very different health needs and demands on general practice this population presents, and that services needed to be adapted to be made more suitable. The practice has developed over time and now provides a comprehensive holistic service that meets the needs of their population.

The areas where the provider must make improvements are:

• The provider must review the procedures for sharing communications from secondary care providers to ensure care and treatment remains safe for people using the service and arrangements are in place to share and identify safeguarding concerns.
• The provider must update risk assessments for the management of legionella at all locations.
• The provider must review and improve access to the practices by telephone and improve appointment availability with consideration for patient feedback.
• The provider must monitor progress against action plans to improve the quality and accessibility of services.
• The provider must review assessments to ensure that premises and equipment are appropriately used and maintained.

The areas where the provider should make improvement are:

• The provider should put systems in place to record receipt of blank prescription forms at Highgate.
• The provider should risk assess the use of blinds and the type of blind cords used at all locations in line with advisory Department of Health guidance, February 2015.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice