The Care Quality Commission
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Archived: St Nicholas Health Centre

Overall: Requires improvement read more about inspection ratings

Canterbury Way, Stevenage, Hertfordshire, SG1 4LH (01438) 747064

Provided and run by:
St Nicholas Health Centre

All Inspections

30/11/2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at St Nicholas Health Centre on 30 November 2016. This inspection was undertaken to follow up on a Warning Notice we issued to the provider and the registered manager in relation to Regulation 12; Safe Care and Treatment

with regards to areas of unmanaged risk, lack of process for significant events and incidents and in the event of a major incident. A lack of process for the safe management of blank prescriptions, a lack of systems for regular fire drills, infection prevention and control procedures and checks and the monitoring of the safety of staff and patients through the effective management of clinical staff vaccinations and the management of Legionella.

The practice received an overall rating of requires improvement at our inspection on 20 July 2016. We issued a warning notice and this report only covers our findings in relation to the areas identified in the warning notice as requiring improvement during our inspection in July 2016. You can read the report from our last comprehensive inspection in July 2016, by selecting the 'all reports' link for St Nicholas Health Centre on our website at www.cqc.org.uk. The areas identified as requiring improvement in our warning notice were as follows:

  • We found that lessons learnt from significant events were not being shared with all of the relevant staff at the practice.
  • We found that there was no record of clinical staff vaccinations available to us during the inspection.
  • We found that there was no risk assessment in place for the control of substances hazardous to health.
  • We found that no action had been taken following the completion of a Legionella assessment in March 2016.
  • We found that there was no process in place that would identify if blank prescriptions were missing or used inappropriately.
  • We found that there was no record of previous fire drills undertaken at the practice.
  • We found that there was no business continuity plan in place for major incidents such as power failure or building damage.
  • We found that there were inadequate systems in place to assess the risk of and to prevent, detect and control the spread of infection.

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

  • The practice had complied with the warning notice we issued and had taken the action required to comply with legal requirements.
  • There was an effective system in place for reporting, recording and sharing of learning from significant events with all of the relevant staff at the practice.
  • The practice maintained an accurate record of clinical staff vaccinations and this was checked on a regular basis by a named lead.
  • The practice had completed a risk assessment to effectively monitor the control of substances hazardous to health.
  • The practice had acted on all of the requirements which had been identified in the legionella risk assessment and were completing the required checks on a regular basis.
  • The practice has a system in place to monitor the use of blank prescriptions.
  • The practice had completed a fire drill and had updated their fire risk assessment to ensure fire drills were carried out on a regular basis.
  • The practice had created a business continuity plan which had been shared with all staff members.
  • The practice had reviewed and improved their infection prevention and control systems and processes. The practice carried out regular checks and had completed an infection control audit.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

20/07/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Nicholas Health Centre on 20 July 2016. Overall the practice is rated as requires improvement.

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. However, there was no evidence of learning and communication with staff in relation to reporting incidents and concerns.
  • Not all governance structures, systems and processes were effective and enabled the provider to identify, assess and mitigate risks to patients, staff and others.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Patient comments highlighted that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Improvements were made to the quality of care as a result of complaints and concerns. However, information about how to complain was not easily available.
  • Patient comments highlighted that they found it easy to make an appointment with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Introduce systems to alert the practice of emerging risks such as in infection control, arrangements to deal with emergencies, fire safety, control of substances hazardous to health, significant events, staff appraisal, supervision and training.
  • Ensure an accessible and effective system is in place so that patients are appropriately informed regarding how to make a complaint, including the recording of verbal complaints.
  • Implement the actions required for the completion and effective management of all of the risks identified in the Legionella risk assessment.
  • Ensure an appropriate system is in place for the safe monitoring of prescriptions.
  • Ensure all clinical staff receive vaccinations in line with current national guidance and an effective system is in place to maintain a record of staff vaccinations.

The areas where the provider should make improvements are:

  • Carry out a review of the practice policies to ensure they are practice specific and meet current legislation and guidance.
  • Continue to monitor the results from the National GP Patient Survey and establish an action plan for areas which are identified as requiring improvement.
  • Review the services available to patients who are hard of hearing or do not have English as their first language.
  • Engage with the virtual Patient Participation Group in the delivery of the services provided.
  • Ensure appropriate recruitment checks are completed for all non-clinical staff and an effective system is in place for the required checks to be undertaken prior to employment.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice