The Care Quality Commission
  • Doctor
  • GP practice

Cleckheaton Group Practice Also known as St John's House

Overall: Good read more about inspection ratings

Cross Church Street, Cleckheaton, West Yorkshire, BD19 3RQ (01274) 957846

Provided and run by:
Cleckheaton Group Practice

All Inspections

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

18 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs SL Nicholls, S M Nicholl, HL Hughes, & Ninan - St John's House on 18 August 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Improvements had been made to the premises which included increasing the number of clinical rooms, new flooring, improved facilities for staff and providing a range of seating in the waiting area for patients with limited mobility.
  • The practice sought to increase the services available to patients by signing up to enhanced services. For example, the care co-ordinator pilot, 24 hour blood pressure monitoring, minor surgery and electrocardiograms (ECGs).
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Review the support and training provided for the infection control lead to help them to carry out their role effectively.
  • Review the arrangements for the laundering of curtains in clinical areas in accordance with the current guidelines.
  • The practice should review the clinical staff who are invited to attend the weekly informal clinical meetings held at the practice.

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

On our previous inspection we found that the provider did not follow effective recruitment and selection processes. This meant they could not be assured of the good character of their future or current employees.

We have now received documentation which showed the provider now operates a robust and effective recruitment and selection procedure. The information we received included evidence that all current staff had been checked by the Disclosure and Barring Service (DBS) to assure that they were all of good character and fit to carry out the regulated activities for which the provider was registered. Regulation 21 (a) (i).

24 September 2013

During a routine inspection

As part of our inspection we spoke with four patients who used the service, four staff members, a doctor, who was also the registered manager, a nurse practitioner, the acting practice manager and three reception staff.

The practice had a 'Patient Participation Group' (PPG) who met regularly to discuss the services provided by the practice. They told us they expressed their views and were involved in making decisions about the practice. They said the doctors listened to them and the reception staff were 'Really helpful.' They said patients were able to visit the surgery and were always guaranteed to see a doctor.

Other patients told us they felt confident about returning to the surgery to see their doctor should they find their medication was not working. They also said they had been offered options in planning their treatment. There were examples of how the practice offered choice, treatment and support to meet people's needs.

All staff had received abuse awareness training and procedures were in place to respond appropriately to any allegation of abuse.

Appropriate recruitment checks were not in place prior to the employment of staff. We have judged that this has a minor impact on people who use the service, and have told the provider to take action.

People had their comments and complaints listened to and, where appropriate, action had been taken.