We carried out an announced comprehensive inspection at the Clays Practice on 20 February 2019 as part of our inspection programme.

At this inspection, we visited the main location the Clays Practice in Roche, Cornwall. There is a dispensary at the Roche site, which was inspected. The practice has two branch surgeries, which we did not visit but reviewed governance arrangements monitoring these.

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 safe and well led as requires improvement because w

e found that:

• We found some gaps in recording of actions taken to mitigate risks and overall governance was not effective because: The recording and analysis of significant events in the dispensary did not evidence information gathering, analysis, shared learning and monitoring of change. The requirement to ensure each patient requiring a care plan had one had not been fully implemented and was not picked up by the practice.
• Exception reporting was not applied in accordance with guidelines and led to inaccurate negative data for the   practice. Alert systems to assist non-clinical staff in identifying a deteriorating or acutely unwell patient were not embedded when a long-term condition increased risks for a patient.

We have rated this practice good for all population groups and effective, caring and responsive because:

• A significant event, which stopped the service from the main site at Roche following a serious flood was very well managed. Patients praised staff for continuing to deliver services from the branch surgeries during this period.
• Safety systems were clear facilitating the management of risk across all the practice, including the branch surgeries. The practice thoroughly investigated safety events reported as such and learned from them to improve processes and patient experience.
• Staff demonstrated a willingness to immediately make changes resulting from feedback given at the inspection, examples were: The care plan consolidation action plan submitted within 48 hours showed completed actions and planned to be resolved by the end of April 2019.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice was performing higher in several parts of the national GP patient survey.
• All patients providing feedback during the inspection were strongly positive about the practice. Staff were said to be compassionate, friendly and went the extra mile to support patients and their carers’.
• Audit was used to identify in-depth learning and implement changes to improve patient care and treatments.
• Succession planning and staff development was proactive and created a flexible and responsive workforce.

The area where the provider must make improvements are:

Established effective systems and processes to ensure good governance in accordance with the fundamental standards of care to manage and mitigate risk.

Ensure that each patient who requires it has a care plan which shows their needs have been assessed and shows what care is planned and how it will be delivered in line with current legislation.

The areas where the provider should make improvements are:

• Raise awareness of the significant event (SEA) processes to ensure there is consistent documentation of risks, actions, change and embedding for safe governance.
• Review the way emergency medicines and equipment is organised to facilitate effective monitoring of expiry dates.
• Review the standard operating procedure for the return and destruction of controlled drugs in line with the Misuse of Drugs (Safe Custody) regulations.
• Review quality improvement systems to increase audit to monitor clinical effectiveness through patient registers.
• Increase the identification and assessment of carers’ to ensure their needs for support are met.
• Improve the uptake of cervical screening
• Consider further ways to engage and support hard to reach families in the community, including making them aware of healthcare immunisation available for their children.

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

Letter from the Chief Inspector of General Practice

We undertook a planned, comprehensive inspection of The Clays Practice on 11February 2015. The practice provided primary medical services to people living in the village of Roche and surrounding villages in Cornwall. The practice also had two other branch surgeries in St Dennis and Bugle that were open every weekday morning.

The practice comprised of a team of five GP partners (four male and one female) who held managerial and financial responsibility for running the business. In addition there were one and a half salaried GPs, four registered nurses, six qualified dispensers and three health care assistants. There was also a comprehensive administrative team that consisted of a full time practice manager, a deputy practice manager, receptionists and administration staff.

Patients who used the practice had access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

The practice had a dispensary attached. A dispensing practice is where GPs are able to prescribe and dispense medicines directly to patients who live in a rural setting. The Clays practice dispensed to patients who did not have a pharmacy within a mile radius of where they lived.

The practice is rated as good. A safe, caring, effective, responsive and well-led service was provided that met the needs of the population it served.

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Our key findings were as follows:

• Patients reported having good access to appointments at the practice. The practice was clean, well-organised, had good facilities and was well equipped to treat patients.

• The practice valued feedback from patients and acted upon this. Feedback from patients about their care and treatment was consistently positive. The culture of the practice was patient centred. Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. Views of external stakeholders were very positive and were aligned with our findings.

• The practice was well-led and had a clear leadership structure in place. There were systems in place to monitor and improve quality and identify risk and systems to manage emergencies.

• There were arrangements for the efficient management, storage and administration of medicines within the practice and within the dispensary.

• Patients told us they felt safe, that staff were professional and they felt confident in clinical decisions made. There were effective safeguarding procedures in place.

• Significant events, complaints and incidents were investigated and discussed. Staff learned from these events and shared their learning within the team.

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

Importantly, the provider must:

Ensure that each patient who requires it has a care plan which shows their needs have been assessed and shows what care is planned and how it will be delivered in line with current legislation.

Recruitment processes must be improved to include proof of identity, including a recent photograph, references, a full employment history, and a risk assessment to determine the decision regarding carrying out a criminal record check, using the Disclosure and Barring Service (DBS).

In addition the provider should:

Staff training records should be improved so that staff that need training updates are easily identifiable.

Treatment rooms should be kept locked when not in use in order to ensure the security of blank prescription forms and other sensitive material.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice