Archived: Joydens Wood Medical Centre

We carried out an unannounced comprehensive inspection at Joydens Wood Medical Centre on 19 November 2019 due to concerns raised by patients and other stakeholders. This was the providers first inspection since registering with CQC in July 2019.

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 Inadequate overall.

We rated the practice as Inadequate for providing safe services because:

• The practice did not always have clear systems, practices and processes to keep people safe and safeguarded from abuse.
• The practice did not have effective recruitment systems and processes.
• Risks to patients were not appropriately assessed and any actions required to address or minimise risk, had not been completed.
• The premises were not always fit for purpose and actions from risk assessments were not undertaken, to reduce the risk of fire and legionella.
• Appropriate standards of cleanliness and hygiene were not always met.
• Staff did not always have the information they needed to deliver safe care and treatment.
• The practice did not have appropriate systems for the safe management of medicines.
• The practice did not have an effective system to learn and make improvements when things went wrong.

We rated the practice as Inadequate for providing effective services because:

• Care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance.
• There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• Staff did not always work together and with other organisations to deliver effective care and treatment.

We rated the practice as Requires improvement for providing caring services because:

• The practice was unable to demonstrate how they made use of feedback from patients.
• The practice did not always respect patients’ privacy and dignity.

We rated the practice as Inadequate for providing responsive services because:

• The practice did not always organise and deliver services to meet patients’ needs.
• People were not always able to access care and treatment in a timely way.
• Complaints were not always used to improve the quality of care.

We rated the practice as Inadequate for providing well-led services because:

• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
• The practice did not have a clear vision, supported by a credible strategy to provide high quality sustainable care.
• The practice culture did not effectively support sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks and identified issues.
• The practice did not always act on appropriate and accurate information.
• The practice did not always involve the public, staff and external partners to sustain high quality and sustainable care.
• There was no evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups, so we rated all population groups as Inadequate

We took urgent enforcement action and served an Urgent Suspension Notice on the service provider’s registration in respect of the regulated activities carried out at all registered locations (Joydens Wood Medical Centre and Elmdene Surgery, including the two branch practices at Bean Surgery and Bennett Way Surgery). The urgent suspension for all registered locations took effect on 26 November 2019. We took this action as we believe that a person will or may be exposed to the risk of harm if we did not do so.

As there are exceptional circumstances in this instance, CQC have considered that placing the practice into special measures would not be appropriate at this time.

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