This practice is rated as Good overall. (Previous rating 09 2017 – Requires improvement).

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Clay Cross Medical Centre on 3 July 2018. At the previous Care Quality Commission (CQC) inspection in July 2017, the practice received an overall requires improvement rating. The practice was deemed to require improvement for providing effective and well-led services, but was rated as good for providing safe, caring and responsive services. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Clay Cross Medical Centre at . This inspection was undertaken to ensure that improvements that had been made following our inspection in July 2017.

At this inspection we found:

• We found that there had been some significant improvements within the practice. The appointment of a new practice manager and a restructuring of the management team was helping to drive improvements.
• Building on the action plan developed from previous inspections, a wider practice development plan was in place to plan for the future.
• Following some personnel changes within the practice team over the previous year, there had been difficulties in providing continuity, particularly in respect of nursing. This had stabilised by the time of our inspection, giving a stronger foundation for further development.
• We observed that staff turnover had impacted significantly on the practice’s performance in the 2017-18 achievement for the Quality and Outcomes Framework (QOF), which had decreased by approximately 20%. This also impacted on a relatively low number of patients with a learning disability having an annual review of their needs. However, a plan had been produced to rectify this, and we observed that improvements were being made.
• The practice ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The partners acknowledged that more GP capacity was required and continued to try and address this. However, skill mix arrangements with advanced nurse practitioners and a part-time pharmacist provided more options for patients to see the right professional to meet their own needs.
• Appointment systems had been recently revised and we observed that this was facilitating easier access to care when it was needed. The procurement of a new and improved telephone system was nearing completion which would impact positively on patient experience.
• There was a stronger focus on listening to patients and responding to their feedback. An action plan had been developed in response to a recent internal patient survey, and we saw how this aimed to respond positively to what patients had said.
• The practice encouraged learning and improvement, and we saw that staff were up to date with the practice’s training schedule.
• The Clinical Commissioning Group’s (CCG) medicines management team told us that the practice engaged well with them. However, there was scope for further improvement in reducing the prescribing of broad-spectrum antibiotics, and cost-effective prescribing in line with guidance.
• The practice had established good working relationships with other local GP practices and the GP federation, and this collaborative work was producing good outcomes in improving services for patients and the practice team.

The areas where the provider should make improvements are:

• Improve quality of care and patient outcomes as part of annual QOF performance.
• Continue to review the prescribing of broad-spectrum antibiotics.
• Ensure an effective immunisation programme is in place to include records to confirm the immunisation status of staff who have direct contact with patients.
• Take action to ensure higher rates of patients with a learning disability are seen for an annual review of their needs.
• Continue to identify patients who are carers and ensure they receive appropriate advice and support.
• Develop more comprehensive evidence of discussion at clinical and management meetings to reflect discussions of topics such as complaints, significant events and new guidance.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Clay Cross Medical Centre 2 November 2016 and 10 November 2016. The overall rating for the practice was inadequate; specifically the practice was rated as inadequate for providing safe, effective and well-led services, good for providing caring services and requires improvement for providing responsive services. The practice was placed in special measures for a period of six months. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Clay Cross Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 14 July 2017. Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• The practice had achieved good progress and improvements in tackling the issues identified at the previous inspection. However, an agreed and deliverable plan for a sustainable future was still required.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. The practice had a nominated lead for significant events and held regular meetings to review events and disseminate learning.
• The practice had clearly defined and embedded systems to minimise risks to patient safety. Risks were identified, assessed, monitored and reviewed on a regular basis.
• Staff were aware of current evidence based guidance. Systems for sharing updates to guidance had been reviewed and improved.
• Patient outcomes were improving; for example, in respect of non-elective admissions.
• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. Learning from complaints was identified and shared with relevant staff.
• Patients we spoke with said they were generally able to make an appointment with a GP, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff were positive about changes to the management arrangements. However, some of the underlying shortage of clinical capacity remained a concern.
• The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

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

The provider should:

• Continue to review and improve the management of patients with long term conditions.
• Continue to increase the number of carers identified.
• Provide patients with a learning disability with regular health checks.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service. It remains important that the practice continue to develop a plan for the future. 

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 Clay Cross Medical Centre on 2 November 2016 and 10 November 2016. The overall rating for the practice was inadequate. The full comprehensive report from November 2016 can be found by selecting the ‘all reports’ link for Clay Cross Medical on our website at www.cqc.org.uk.

The overall rating of inadequate will remain unchanged until we undertake a further full comprehensive inspection of the practice within the six months of the publication date of the report from November 2016.

This inspection was a focused inspection carried out on 31 January 2017 to confirm that the practice had taken the required action to meet the legal requirements in relation to the breaches in regulation set out in a warning notice issued to the provider. The warning notice was issued in respect of a breach of regulation related to safe care and treatment; specifically the practice was failing to ensure appropriate action was being taken to mitigate risks in respect of the prescribing of contraindicated medicines.

Our key findings were as follows:

• The practice had complied with the warning notice we issued and had taken the action needed to comply with legal requirements.
• Audits of patient records had been undertaken to identify any affected patients and appropriate action had been taken to address any identified issues.
• Searches of the practice’s patient record system demonstrated action had been taken to address identified areas of concern in respect of the prescribing of contraindicated medicines.
• Improvements had been made to the system for the receipt and management of alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).

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 Clay Cross Medical Centre on 15 September 2015. Overall the practice is rated as requires improvement. Our key findings across the areas we inspected were as follows:

• Feedback from patients was consistently positive about the care and treatment they received, and the way staff treated them. Patients were treated with kindness, dignity and respect.
• Patients were able to access care and treatment when they needed it, and most people could access appointments and services in a way, and at a time that suited them.
• The number of appointments available each week had increased following the recent appointments of additional clinical staff.
• Staff worked closely with other services to ensure that patients’ needs were met.
• Overall, systems were in place to keep patients safe although aspects of infection control, chaperone and recruitment procedures required strengthening.
• The practice had appropriate facilities and was well equipped to treat patients and meet their needs.
• The systems for identifying and learning from safety incidents and significant events required strengthening.
• There was an open, positive and supportive culture. Staff were actively supported to develop their knowledge and acquire new skills to provide high quality care.
• The clinical leadership required strengthening to ensure a practice wide approach to care and treatment in line with best practice. The practice was undergoing various changes following the appointment of additional clinical staff.
• The practice actively sought feedback from patients, which it acted on.

However there were areas of practice where the provider needs to make improvements. Importantly the provider must:

• Follow effective recruitment procedures to ensure all persons employed are of good character, and that all necessary employment checks are available, and that staff who undertake chaperone duties have received a disclosure and barring check or risk assessment.

The areas where the provider should make improvement are:

• Strengthen the systems for identifying and sharing learning from safety incidents and significant events, to prevent further occurrences and minimise risks to patients.
• Update the cleaning schedule to include regular cleaning of the carpets, and replacement of the disposable privacy curtains in the consultation and clinical rooms at the recommended intervals.
• Strengthen the systems for ensuring patients are referred promptly to secondary care services and the appropriateness of referrals.
• Provide relevant training on the Mental Capacity Act 2005 for the nursing and administrative staff to ensure they understand the key parts of the legislation, and how this applies in their practice.
• Strengthen the clinical leadership and governance arrangements to enable the provider to effectively assess, monitor and improve the quality and safety of services provided.
• Provide further opportunities for all clinical staff to discuss new guidelines and agree changes to practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with five patients, a representative of the Patient Participation Group, one GP, one practice nurse, one health care assistant, four reception staff, a community matron and the practice manager during our inspection.

Patients told us they were asked for their consent before any procedures were carried out. We saw written consent forms were used for minor surgical procedures. Patients told us they felt involved in their care and were able to ask questions. One patient told us: “Nurse X is marvellous; they explain what they are doing.” Another said: “The GP reviews my medication every so often, they explain and discuss what medication I am on.”

We saw systems were in place to safeguard children and vulnerable adults. Staff were aware of the appropriate agencies to refer safeguarding concerns to that ensured patients were protected from harm.

We saw that the provider did not have robust recruitment and selection procedures in place for newly recruited staff, and had not assessed the suitability of existing staff to work with patients and access confidential information.

The provider had systems in place for monitoring the quality of service provision. There was an established system for obtaining opinions from patients about the standards of the services they received. This meant that on-going improvements were made by the practice staff.

Letter from the Chief Inspector of General Practice

The practice had previously been inspected in September 2015 and found to be requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. We undertook a further comprehensive inspection in November 2016 to ensure the provider had made improvements.

In September 2015, the provider was found to be in breach of Regulation 19 of the Health and Social Care Act 2008 due to concerns regarding the absence of background checks undertaken for staff acting as chaperones. Following this inspection, the provider was issued with a requirement notice and provided an action plan to the CQC.

We carried out an announced comprehensive inspection at Clay Cross Medical Centre on 2 November 2016 and 10 November 2016. Overall the practice is rated as inadequate.

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

• Systems for reporting and recording significant events were not being operated effectively. Incidents and significant events were not always documented, investigated and discussed in a timely manner.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example the practice did not have effective procedures in place to deal with alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA) or alerts related to patient safety.
• The practice did not have adequate arrangements in place to ensure controlled drugs were stored in line with legislation.
• Health and safety risks to patients and staff were assessed and managed including the risk of fire.
• Some patient outcomes were in line with local and national averages. However the practice was an outlier when compared with other practices in the clinical commissioning group for a number of areas including referrals to secondary care.
• Limited audit and quality improvement work had been undertaken within the practice. Although there was evidence of the practice comparing their performance to others, this was driven by the CCG rather than practice led.
• Although some audits had been carried out in relation to referrals to secondary care, we saw limited evidence that audits were driving improvements to patient outcomes.
• Patients were generally positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice had some leadership structures however there was insufficient leadership capacity and formal governance arrangements needed to be strengthened.
• Information about the performance of the practice was not shared widely with appropriate staff within the practice.

The areas where the provider must make improvements are:

• Ensure patients receive safe care and treatment by; investigating significant events and safety incidents in a timely way including documentation of the findings and dissemination of the learning; ensuring the safe storage and management of medicines including controlled drugs; implementing effective systems and processes for disseminating and acting upon alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).
• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.
• The provider must have effective systems in place to assess and monitor the quality of the service by ensuring they have effective oversight of the performance of the practice and the effectiveness of the clinical care being provided.For example by ensuring internal meetings allow for discussion and learning from events and complaints and by ensuring there is leadership capacity to deliver all improvements.

In addition the provider should:

• Review and update policies and procedures
• Carry out completed clinical audits cycles to improve patient outcomes.
• Improve arrangements for recording of and responding to verbal complaints.
• Review and improve arrangements for the provision of minor skin surgery procedures.
• Continue to try and improve the identification of carers.
• Ensure all documents related to the recruitment of staff are retained and available for review.
• Consider how to improve the engagement of members of the clinical staff team with the patient participation group (PPG).

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice