The Care Quality Commission
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  • GP practice

Claverley Medical Practice

Overall: Requires improvement read more about inspection ratings

Spicers Close, Claverley, Wolverhampton, West Midlands, WV5 7BY (01746) 710223

Provided and run by:
Claverley Medical Practice

All Inspections

05 June 2023

During a routine inspection

We carried out an announced follow up comprehensive inspection at Claverley Medical Practice on 5 June 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 6 April 2022, the practice was rated requires improvement overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Claverley Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

Our focus included:

  • Safe, effective, caring responsive and well led key questions.
  • A follow up of breaches of regulations and ‘shoulds’ identified in previous inspection.

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 and in person on site.
  • 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.
  • A site visit.
  • An interview with a member of the Patient Participation Group.
  • Staff questionnaires.
  • Feedback from external stakeholders.

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 found:

Although improvements had been made in a number of areas we identified ongoing concerns in relation to people receiving safe and effective care.

We rated the provider as requires improvement for providing safe services because:

  • The system to review and act on patient safety alerts continued not to be effective.
  • Some high-risk medicines were not being monitored and prescribed safely in accordance with national good guidance.
  • Dispensing incidents were logged. However, there was no proper investigation or actions implemented to mitigate the risk from reoccurring. The recording was basic and often only involved one person, reporting, recording and documenting outcomes from any one incident.
  • Standard Operating Procedures covered standard practices including all aspects of the dispensary. However, checks were not made to ensure they were being followed.
  • Dispensary staff had received training to carry out their roles effectively and safely. However, there was no assurances or records of competency checks for longstanding dispensary staff.

We rated the provider as requires improvement for providing effective services because:

  • The routine monitoring of some patients with long-term conditions had not been carried out in line with guidance potentially putting patients at avoidable risk.
  • The quality of medicine reviews undertaken varied.
  • Quality improvement activity required further development to demonstrate improved outcomes for patients.

We rated the provider as good for providing caring services because:

  • Although the practice results in the National GP Patient Survey 2022 did not reflect significant improvement, the practice had received complimentary feedback from a range of sources about people’s experiences of their care. In addition, they had also carried out 2 in-house patient surveys which were positive regarding providing caring services.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the provider as good for providing responsive services because:

  • Although the practice results in the National GP Patient Survey 2022 did not reflect improvement, feedback received from a range of sources showed the practice was more responsive to the needs of their patients.
  • Patients could access care and treatment in a timely way.
  • Complaints were managed in line with policy.

We rated the provider as good for providing well-led services because:

  • Governance structures were becoming embedded into practice.
  • Improvements had been made to the accuracy and effectiveness of policies and these were kept under review and updated.
  • Improvements in relation to the oversight and management of complaints and significant events had been implemented to drive improvement.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

The provider should:

  • Take action to ensure all staff are provided with training to support autistic people and people with a learning disability.

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 Healthcare

6 April 2022

During a routine inspection

We carried out an announced comprehensive inspection at Claverley Medical Practice on 6 April 2022. Overall, the practice is rated as requires improvement. We rated the key questions:

Safe: Requires improvement

Effective: Requires improvement

Caring: Requires improvement

Responsive Requires improvement

Well-led: Requires improvement

At a previous inspection on 12 November 2015, the practice was rated good overall and requires improvement for providing safe services. Breaches in two regulations were identified in relation to safe care and treatment and fit and proper persons employed. We carried out a a follow up inspection on 12 January 2017 to review improvements. The practice was rated good overall and good in providing safe services. No further breaches of regulations were identified.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Claverley Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a comprehensive inspection following concerns we had received in relation to care and treatment and good governance.

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing and on site and a staff questionnaire
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A 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 requires improvement overall.

We rated the practice as requires improvement for providing safe care and treatment because:

  • Siblings at potential risk within a household were not identified on the clinical system.
  • Staff files were well organised but recruitment checks had not always been carried out in accordance with regulations.
  • Controlled drugs were not stored in line with legislation.
  • A breach in the cold chain had not been immediately acted upon or specialist advice sought in order to ascertain what action, if any, was required to ensure the safety and efficacy of vaccines.
  • There were missed opportunities to raise and analyse significant events to allow reflection and learning and improve patient care.
  • The oversight and management of vaccines administered under patient group directions (PGDs) was not effective.
  • Processes for the safe handling of requests for repeat medicines were not effective as not all patients had received the required monitoring.
  • The system to review and act on patient safety alerts was not always effective.

We rated the practice as requires improvement for providing an effective service because:

  • Medication reviews were not always structured and failed to identify some patients who were overdue their monitoring.
  • Staff received an appraisal of their work but the process required review.
  • Further oversight was required for staff working in advanced roles.
  • The practice had undertaken some quality improvement activity but this required further development to demonstrate improvement.

We rated the practice as requires improvement for providing a caring service because:

  • The National GP Patient Survey 2021 results for the practice were lower than local and national averages in respect of providing caring services.
  • Feedback from patients was varied about the way staff treated them.

We rated the practice as requires improvement for providing a responsive service because:

  • The National GP Patient Survey 2021 results for the practice were lower than local and national averages in three of the four indicators in respect of providing responsive services.
  • The practice had not always been responsive to the needs of their patients.
  • Complaints were not always managed effectively. Opportunities to record complaints had been missed to improve the quality of care.

We rated the practice as requires improvement for providing a well-led service because:

  • Governance structures, processes and systems were being developed but were not yet embedded into practice.
  • Policies were available but systems to ensure accuracy were not always effective.
  • There was no overarching system in place to identify trends in complaints or significant events or to review the effectiveness of any possible changes made within the practice.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Ensure staff employed receive protected time to fulfil their lead roles.
  • Develop a quality improvement programme with a formalised improvement plan.
  • Ensure siblings at potential risk within a household are identified on the clinical system.
  • Ensure all recruitment checks are carried out in accordance with regulations.
  • Consider ways of improving patient experience.

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

12 January 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Claverley Medical Practice on 12 November 2015. A total of three breaches of legal requirements were found. After the focussed inspection, the practice was rated as requires improvement for being safe.

We issued requirement notices in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.
  • Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Claverley Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 12 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 12 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Risks to patients were assessed and well managed. The practice had improved its procedures to ensure appropriate recruitment checks had been completed.
  • Ongoing audits were driving improvement in performance to improve patient outcomes.
  • Patients’ needs were assessed and care was planned, and best practice guidance was followed.
  • Procedures had been reviewed and systems introduced to ensure the safe management of medicine practices, which included effective procedures to monitor patients prescribed high risk medicines.
  • Infection control audits had been completed and facilities improved to reflect nationally recognised guidance.
  • Improvements had been made to protect patient confidentiality at the practice branch site.
  • There was a clear leadership structure and staff felt supported by the management.
  • The practice proactively sought feedback from patients.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

At our previous inspection on 12 November 2015, we rated the practice as requires improvement for providing safe services. At this inspection we found that the practice had resolved all the concerns raised and is now rated as good for providing safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12/11/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Claverley Medical Practice on 12 November 2015. Overall the practice is rated as good.

Our key findings were as follows:

  • Patients valued the staff at the practice and told us they had a high level of involvement in their own care and treatment.

  • The practice was responsive to the needs of the local population including older patients by providing proactive visits for those who lived in care settings.

  • Patients were mostly happy with the appointments system, although some patients told us they waited longer to see their preferred GP.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ medical conditions were mostly well managed, although patients who took a specific medicine, prescribed for patients with a long-term condition had not consistently received monitoring for side effects as suggested in national guidance.
  • Patients told us they always found the practice to be clean. We saw examples of infection control practice that was not in line with nationally recognised guidance.

We saw an area of outstanding practice

  • The practice had been highly effective at providing seasonal flu vaccinations for all patients, but in particular children. Data showed that the practice had performed well above local and national averages in providing the seasonal flu vaccination to children aged two to four years old. The practice told us they had done this by engaging with childhood settings to promote the benefits. The practice was the highest performing practice in this outcome in the clinical commissioning group area and the percentage of patients who receive the vaccine was over twice the national average.

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

Importantly, the provider must:

  • Follow nationally accepted guidance for the monitoring of patients who take Methotrexate.

  • Ensure that risks to patients and staff from infection are minimised by adopting best practice infection, prevention and control guidance. This includes completing, recording and acting upon findings from regular infection control audits.

  • Ensure that the recruitment of staff includes a satisfactory assessment and recording of information of any physical or mental health conditions that may affect the role they are to undertake.

In addition the provider should:

  • Consider the implementation of guidance issued by Public Health England on the storage of vaccines. In particular, at Claverley consideration of a second method of checking fridge temperature. At Pattingham ensuring a consistent system of checking the storage of medicines is in line with the guidance.

  • Improve security for the issue and tracking of blank prescription forms to reflect nationally accepted guidance as detailed in NHS Protect.

  • Provide a system of regularly assessing the performance and development needs of members of staff.

Explore methods to ensure conversations in the consultation room at Pattingham cannot be overheard.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

At our previous inspection on 6 November 2013 we found that improvements were needed to ensure that the provider made appropriate checks in the recruitment of staff at the practice.

The provider sent information to us to show that the required improvements had been made. We checked this evidence. We saw that changes had been made and revised recruitment procedures were now in place and were being followed by the practice.

6 November 2013

During a routine inspection

We spoke with six patients during our inspection. Most patients we spoke with were complimentary about the service they received at the practice. They told us that the doctors were, 'Very very good', that the receptionists were, 'Delightful' and that, 'Everyone always smiles'. Some patients told us that it was not always easy to get an appointment when they wanted one.

We saw that the practice had procedures in place to help protect patients' privacy and dignity. The staff we spoke with were familiar with the procedures. None of the patients we spoke with had any concerns in this area.

We found that care and treatment was planned and delivered in a way that met patients' needs and protected their rights. Patients were able to be involved in decisions about their treatment.

We found that medicines kept in the practice were stored in a safe and secure way. The staff regularly checked the medicines to ensure that they remained in date.

We were not satisfied that the provider made all the appropriate checks on staff before their full employment started. The practice manager regularly checked to ensure that healthcare professionals employed at the practice were correctly registered with their appropriate professional body.

We saw that the practice carried out a range of audits on a regular basis to monitor the quality of its own performance and to learn from any mistakes made. The practice had an active and effective patient participation group.