20 February 2018
During a routine inspection
This practice is rated as Requires Improvement
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Requires improvement
Are services caring? – Good
Are services responsive? – Requires improvement
Are services well-led? - Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires Improvement
People with long-term conditions – Requires Improvement
Families, children and young people – Requires Improvement
Working age people (including those retired and students – Requires Improvement
People whose circumstances may make them vulnerable – Requires Improvement
People experiencing poor mental health (including people living with dementia) - Requires Improvement
We carried out an announced inspection at Brierley Medical Centre on 20 February 2018 as part of our inspection programme. We also carried out an announced comprehensive inspection at Barnsley Healthcare Federation CIC head office based at Oaks Park Primary Care Centre on 13 and 14 February 2018 to look at governance as part of our inspection programme.
At this inspection we found:
- There was no open and transparent approach to safety and no effective system in place for recording, reporting and learning from significant events.
- The practice did not routinely review the effectiveness and appropriateness of the care it provided. There was limited evidence of audits and quality improvement activities to demonstrate monitoring and assessment of the service was being undertaken since the service registered in January 2016.
- There was a system in place for disseminating NICE guidance. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients told us through CQC questionnaires, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
- There was a lack of overarching governance arrangements in place that meant patients were not kept safe from avoidable harm.
- There was a leadership structure but communication between staff and management was limited and some staff felt unsupported by the senior management team.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure governance arrangements are in place to keep patients safe from avoidable harm.
- Ensure that there is an accessible system for identifying, handling. Investigating and responding to complaints made about the service.
The areas where the provider should make improvements are:
- Review the chaperone policy is clearly advertised through patient information leaflets, websites (where available) and on notice boards.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice