Jordanthorpe Health Centre - Care Quality Commission

Background to this inspection

Updated 25 October 2017

The provider, Sheffield Health and Social Care NHS Foundation Trust provides a wide range of specialist mental health, learning disability, drug and alcohol misuse and social care services to the people of Sheffield. From 1 April 2011 it became the provider of additional community and primary care services known as The Clover Group. The group which is made up of the main site at Jordanthorpe Health Centre and has three branches at Darnall Primary Care Centre, Highgate and Central Health Clinic also known as Mulberry. The Group has an additional location, Clover City Practice which is registered with the Care Quality Commission separately.

The organisation is an NHS Foundation Trust, accountable to NHS Improvement (NHSI) and the Department of Health.

The four Clover Group Practices serve some of the city’s most vulnerable areas. They have 16,413 patients with 60% of the patient population from black and other ethnic communities. There are significant numbers of European migrants registered with the practices.

The branch known as Mulberry is based in Sheffield City Centre and provides a specialist service to asylum seekers. This service includes a resettlement programme for immigrants entering the country and providing GP access to the homeless population and victims of trafficking.

The clinical team comprises of 9.95 whole time equivalent (WTE) salaried GPs, 6.83 advanced nurse practitioners, 3.75 WTE practice nurses, 2.11 WTE health care assistants and 0.82 WTE phlebotomists. The clinical team are assisted by support managers at three sites and a large administration and reception team. There is also a central senior management team which includes a Service Lead Manager, Clinical GP Lead and Operational Manager.

The practices are open between 8am and 6pm on Monday, Tuesday, Wednesday and Friday. On Thursdays the telephone lines are transferred at midday at three sites to the Mulberry practice where there is a duty doctor on call. Appointments are available at various times during the day across all sites these include drop in clinics, pre bookable appointments and telephone triage.

One of the practices within the Clover Group (which was not inspected as part of this inspection) offers Saturday morning clinics which are available to all patients within the group. Patients had access to the services provided through the Extended Access hub sites across the city up until 10pm during evenings and weekends.

Overall inspection

Good

Updated 25 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jordanthorpe Health Centre on 14 and 15 November 2016. The overall rating for the practice was requires improvement with requires improvement in safe and responsive.

We also carried out an unannounced focused responsive inspection on 13 June 2017 following feedback to the Care Quality Commission which raised specific concerns about care and treatment and management of the Darnall Primary Care Centre site. As we did not look at the overall quality of the service we were unable to provide a rating for the service at this inspection. The full comprehensive report from14 and 15 November 2016 and the focused report from 13 June 2017 can be found by selecting the ‘all reports’ link for Jordanthorpe Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 September 2017 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 and 15 November 2016 and 13 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good. Specifically, following the focused inspection we found the practice to be rated good for being safe and responsive.

Our key findings were as follows:

The provider had implemented a system to review and monitor the risks associated with legionella at all sites.
The provider had implemented a procedure for sharing communication from secondary care providers.
The provider had reviewed the action plans implemented following feedback from staff and patients to include sufficient detail to monitor progress particularly with regard to access.
The provider had implemented a system to ensure blank prescriptions were held securely at all sites and there was a system for tracking their use, including receipt into each site.
Systems to ensure patient identifiable information was held securely had been reviewed and updated.
Effective systems to monitor infection prevention and control (IPC) procedures had been implemented.
We saw evidence administration tasks were actioned in a timely manner and there was a contemporaneous record maintained in patients’ medical records. Staff we spoke with had a good understanding of the process, though the task policy was not sufficiently detailed to promote consistency across the sites.
The provider had completed a risk assessment of the blinds and type of blind cords used at all sites in line with advisory Department of Health guidance, February 2015. All blinds in patient accessible areas had been made safe. They had either been replaced or had safety mechanisms installed for the cords.
A plan of continuous clinical audit had been implemented. For example, the diabetic audit was now completed monthly at all sites to ensure appropriate monitoring and recording of a new diagnosis in medical records. The diabetic protocol was discussed and enforced with the doctors at an in-house training event on 13 September 2017 to ensure continual improvement in the management of these patients.

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

The provider should:

Review the task policy to include clear guidelines for all staff at each stage of the process.
Continue to monitor the access and capacity plan and patient feedback with regard to improving timely access to appointments.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice