8 and 9 November 2022
During a routine inspection
We carried out an announced comprehensive inspection at Cleckheaton Group Practice (also known as St John’s House) on 8 and 9 November 2022. Following this inspection, we rated the practice as good overall, and requires improvement for providing safe services.
Safe - requires improvement
Effective – good
Caring - good
Responsive - good
Well-led - good
Why we carried out this inspection
This announced comprehensive inspection was carried out in line with our inspection priorities.
The practice was previously inspected on 18 August 2016 and rated good overall and good for all key lines of enquiry. The full report for the previous inspection can be found by selecting the ‘all inspection reports and timeline’ link for Cleckheaton Group Practice on our website at www.cqc.org.uk.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- Reviewing staff questionnaires.
- A shorter site visit.
Our findings
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 good overall.
We found that:
- There were gaps in the management of systems and processes to ensure safe recruitment, premises, infection prevention and control and some medicines management.
- Patients could access care and treatment in a timely way.
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- There was a system in place for reporting and recording significant events.
- Clinicians reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The clinical and management team demonstrated that they understood the challenges to healthcare provision.
We found one breach of regulation. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
The provider should:
- Continue to monitor and make improvements to increase the provision of severe mental health (SMI) and learning disability health checks.
- Review the process to formally document the reviews of the consultation notes and prescribing of the staff provided through the primary care network staff.
- Continue to review the outcome of patient feedback to drive improvement in patient experience.
- Continue to recruit patients to join the Patient Participation Group to establish a group representative of the practice population.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services