Cleckheaton Group Practice Also known as St John's House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that patients were protected from abuse and avoidable harm. At our last inspection, we rated this key question as requires improvement and issued a breach of Regulation 12 (Safe care and treatment), as there were gaps in systems and processes to ensure safe recruitment, premises, infection prevention and control and some medicines management. At this assessment, we found the practice had made improvements to all areas of concern and is now rated good. In particular, we found the practice had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. There were systems in place to ensure people were safe and safeguarded from abuse. Staff understood and managed risks. The facilities and equipment met the needs of patients and were clean and well-maintained. Staff had the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. There were systems and processes in place to support medicines management. A review of patient clinical records found that patients’ medicines management and treatment were safely managed by the practice. Prescribing outcomes were in line with local and national averages.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice demonstrated a proactive and positive culture of safety, based on openness and honesty. Leaders told us that they promoted a culture of learning and encouraged staff to report incidents openly. Staff were able to explain the process of how they would report an incident or who they would seek guidance from to do so. They told us they were encouraged to report incidents and felt confident to do this. The practice had systems and processes in place, underpinned by policies, to formally manage incidents and complaints. At this assessment we reviewed a selection of incidents and complaints and saw appropriate action had been taken and learning shared through meetings. We saw evidence in the investigation of an incident that the practice had applied the duty of candour. We reviewed a sample of minutes and we saw evidence that incidents and complaints had been discussed.

Leaders told us they worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and/or monitored. We found the practice had formal policies in place to manage referrals, clinical correspondence, pathology results and medical record summarising. We observed that urgent 2-week wait cancer referrals were dealt with appropriately and a system was in place to ensure they were sent in a timely manner and that patients had attended for their appointment. Pathology results were actioned by clinicians and there was a buddy system in place for when staff were absent. In addition, there was a system in place for safety-netting cervical screening undertaken at the service, ensuring that a result was received for each cervical screening sample undertaken by their sample takers. We saw incoming patient correspondence was appropriately managed and actioned, including changes to patients’ medications which was undertaken by the clinical and pharmacy team. Clinical records of new patients were mostly received by electronic transfer and those that were received in paper form were summarised in the practice’s clinical record system. At the time of the assessment, the practice had not completed a recent audit of the summarising process. After the assessment, the practice updated their policy and advised us they had added a summarising audit to their audit schedule, to ensure medical records were summarised in line with their policy.

The practice had systems and processes in place to identify, record and action safeguarding concerns, which included the development of safeguarding policies. There was a safeguarding children and adult clinical lead supported by a safeguarding administrator, who was responsible for safeguarding-related recalls and workflow. We saw there were systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations. Staff feedback indicated that all staff knew who the safeguarding children and adult lead was and how to access safeguarding policies. Records showed that all staff had undertaken training for safeguarding children and adults, preventing radicalisation, Mental Capacity Act (MCA), Deprivation of Liberty Standards (DoLS), learning disability and autism awareness relevant to their role and in line with guidance. Staff we spoke with confirmed they had undertaken training and were able to give examples of how they would report and escalate safeguarding concerns. There were systems in place to identify vulnerable patients on their clinical records and staff were aware of this. As part of this assessment, we reviewed 2 safeguarding records and found evidence of safeguarding alerts and appropriate codes on the records of children and their siblings. However, not all family/household members were linked. The practice was proactive to feedback and told us after the assessment that they had commenced a search and audit of child safeguarding records to ensure they were appropriately coded. We saw there were monthly multi-disciplinary safeguarding meetings. Staff who acted as a chaperone were trained for the role and had received a Disclosure and Barring Service (DBS) check. At our on-site inspection we observed notices displayed in the practice to advise patients that a chaperone service was available, if required.

The practice worked with people to understand and manage risks and provided care to meet patients’ needs that was safe. At our on-site assessment we observed that the practice was equipped to respond to medical emergencies, including suspected sepsis. We found the practice held appropriate emergency medicines safely and monitored stock levels and expiry dates. Records confirmed that staff had completed on-line basic life support (BLS) for infants, children and adults, anaphylaxis and sepsis training. Both clinical and non-clinical staff had also undertaken face-to-face BLS training, which the practice did annually. Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example the automated external defibrillator (AED). Medical gases, such as oxygen, were stored safely with appropriate warning signage. Non-clinical staff were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient. Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system integrated into their clinical system.

At our previous inspection, we found gaps in systems and processes to ensure risk assessments had been undertaken to keep premises and facilities safe. At this assessment, we found appropriate risk assessments had been undertaken and actions taken, and contracts were in place to ensure the premises were maintained. We reviewed maintenance documentation and found records for the fire alarm system and fire extinguishers, portable appliance testing (PAT) and calibration of medical equipment. In addition, we saw evidence of a valid gas safety certificate and Electrical Fixed Installation Condition Report (EICR). Risk assessments had been undertaken for fire, health and safety, Control of Substances Hazardous to Health (COSHH) and Legionella and remedial actions had been completed. There was a record of regular fire alarm testing, and a recent fire evacuation drill had been undertaken. All staff had received fire awareness training and there were nominated fire marshals, who had been trained. There was appropriate signage in place, such as for fire escape routes and the fire assembly point.

At our previous inspection, we found gaps in systems and processes to ensure safe recruitment of staff. At this assessment, we found the practice had reviewed their recruitment policies and had implemented procedures to ensure appropriate documentation was in place prior to the commencement of staff. In addition, there was a systematic approach to induction, training and appraisals. As part of our on-site assessment, we reviewed 2 clinical and 1 non-clinical staff recruitment file and found all relevant employment documentation in accordance with regulations was in place. For example, photographic identification, references, Disclosure and Barring Service (DBS) and professional registration checks. All staff were up-to-date with mandatory training identified by the practice and there were records of role-specific training. For example, cervical screening and immunisation. We saw that staff who had been at the practice for more than a year had received an appraisal. The practice could demonstrate how they assured themselves of the competence of staff employed in advanced clinical practice, for example prescribing nurses. We saw this was through consultation and prescribing audits, supported by clinical supervision. A folder was available to locums to provide them with the necessary information to carry out their role safely. The practice told us they actively monitored staffing levels to ensure there were enough qualified, skilled and experienced staff to deliver safe and effective care. They told us a nurse was due to commence shortly.

Feedback from leaders and staff informed us that they had a good understanding of Infection Prevention and Control (IPC). There was a nominated IPC lead and policies in place. Staff knew who the nominated IPC lead was, how to access relevant polices and had received IPC training relevant to their role. We saw that the practice had oversight of the individual immunisation status of staff. From a selection of records reviewed we found that staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance. The practice told us they worked with their occupational health provider to ensure all staff were risk assessed based on their individual role and up-to-date with their vaccine status. We saw some staff were highlighted for vaccine updates and this was being managed by occupational health. On the day of the on-site assessment, we observed the premises to be clean, tidy and clutter-free. The cleaning cupboard was tidy and contained appropriate colour-coded equipment and cleaning materials. We found that colour-coded mops were stored in manner which may pose a risk of cross-contamination. The practice rectified this immediately after the assessment by rearranging the storage and sent photographic evidence of the changes. The arrangements for managing waste and clinical specimens kept people safe. We found posters around the practice including sharps injury, handwashing and clinical waste to support good practice. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff. We spoke with the nominated IPC lead who told us they had dedicated time to undertake this role and had undertaken additional external training to support them in the lead role.

The practice had processes and policies in place to support the management of vaccines, Patient Group Directions and Patient Specific Directions, and blank prescription stationery. As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the procedures around prescribing and medicines management. Overall, we found the systems in place ensured patients prescribed disease-modifying antirheumatic drugs (DMARDs), medicines requiring monitoring and those prescribed medicines subject to a patient safety alert were appropriately managed. The practice had acted upon a finding of our last inspection and put a system in place to record in the clinical notes the outcome of blood tests undertaken in secondary care for warfarin patients, to indicate it was safe to continue prescribing the medicine. An audit of the process had found some lapses in consistency of documentation, and this had been raised with the pharmacy team. We reviewed 2 patient records and found the appropriate documentation in place. A review of medicines usage, in particular the number of asthma patients issued more than 12 short-acting beta 2-agonists (SABAs), showed some patients had not been managed in line with guidance. We saw that 31 patients had been issued more than 12 SABA inhalers in the last 12 months, of which we reviewed 5 records. We found all patients had received an asthma review in the past 6 months but only 1 had received a medication review in the past year, however, the review had not included asthma medication. In addition, the clinical notes did not adequately document or comment on the excess prescribing. The practice told us they planned to review all 31 asthma patients highlighted in our review. There was a process in place for the safe handling of requests for repeat medicines and evidence of medicines reviews for patients prescribed repeat medicines, although the 5 records we reviewed lacked detail.