Archived: Sunnyhill Healthcare C.I.C Also known as Arlesey Medical Centre

We carried out an announced focused inspection at Sunnyhill Healthcare CIC on 12 December 2019 to confirm that the practice had carried out the necessary improvements in relation to their breaches of regulation.

The practice received an overall rating of inadequate at our inspection on 11 September 2019 when warning notices were issued. This rating will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The practice was inspected on 12 December 2019 and found to be compliant with the warning notices.

The full comprehensive report from the September 2019 inspection can be found by selecting the ‘all reports’ link for Sunnyhill healthcare CIC on our website at .

Our judgement of the quality of care at this service is based 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.

Our key findings were:

• The practice was compliant with the warning notices.
• The practice had improved systems around infection prevention and control. Cleaning schedules were in place and audits had been acted on.
• A full record of staff immunisations was held.
• Appropriate risk assessments had been completed, including for health and safety, security and legionella. Mitigating actions that had been identified, such as water temperature checks were being conducted.
• The system to manage patient safety alerts was effective.
• The practice had completed relevant quality improvement activity to make improvements. Audits of the practice of non-medical prescribers had been completed.
• The practice ensured staff had their training needs identified through the appraisal system. This system also gave staff an opportunity to raise concerns and set performance objectives.
• The practice had improved systems around management of significant events, incidents, complaints and patient feedback. We saw systems in place to analyse themes and share learning.

There were areas where the provider should make improvements are:

• Ensure that all patient contacts are recorded in clinical records.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP.

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Sunnyhill healthcare C.I.C. on 11 September 2019 in response to an annual regulatory review.

At the last inspection in March 2017 we rated the practice as good overall.

Our judgement of the quality of care at this service is based 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.

The practice is rated as inadequate overall.

The practice is rated as inadequate in providing safe services because:

• The systems supporting infection prevention and control were lacking. There were areas of the building that showed disrepair and areas that required deep cleaning.
• The practice had not completed a health and safety, security or legionella risk assessment. Shortly after the inspection, we received evidence that a health and safety risk assessment had been completed and an associated action plan developed.
• There was no learning taken or shared from significant events or an analysis of trends.
• The recording of staff immunisation and vaccination was incomplete and did not have self-certification from staff.
• There was no evidence of actions taken from patient medicine and safety alerts.
• Patient Group Directions that allowed non-prescribers to give vaccines were not signed by an appropriate person.
• Emergency medicines were not easily accessible.

The practice is rated as requires improvement for providing effective services because:

• The practice had not reached public health targets for the percentage of eligible patients receiving cervical screening.
• The practice had not completed any quality improvement activity, such as two-cycle clinical audits.
• There was limited oversight of prescribers or formal audit of their practice.
• The system for appraisal was informal and documentation was not detailed.
• The system for following up children who may be at risk was disjointed and there was no fail-safe system in place.

The practice is rated as good for providing caring services because:

• Patients told us staff were caring and compassionate and worked hard to meet their needs.
• The practice had identified 1% of the practice population as carers and offered appropriate support.

The practice is rated as requires improvement for providing responsive service because:

• The practice did not appropriately respond to complaints received and there were no analysis of trends, themes or identification of potential significant events from complaints.
• There was no clear learning identified or shared from complaints.
• Information of how to escalate concerns to the Parliamentary and Heath Service ombudsman was not available to patients.
• There was no analysis of themes from patient feedback.
• GP patient survey results regarding access were in line with local and national averages and patients told us they could make appointments when they needed.

The practice is rated as inadequate for providing well-led services because:

• There were ineffective governance arrangements in place.
• There were ineffective processes to manage risk, issues and performance.
• The practice did not always act on appropriate and accurate information.
• The practice did not always act upon complaints received appropriately, there was a lack of analysis of themes, trends or identification of potential significant events from complaints received or from patient feedback. Learning was not identified and shared with the wider practice team.
• There was no action plan in place for service development or analysis of challenges the practice faced.
• There was no process for organisational audit or risk assessment.

The areas where the provider should make improvements are:

• Improve cervical screening uptake.
• Improve the identification and support for carers.

There were areas where the provider must make improvements as they are in breach of regulation are:

• 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.

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.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care