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Daneshouse Medical Centre Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 February 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection April 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We undertook a comprehensive inspection of Daneshouse Medical Centre on 5 April 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as inadequate, and we issued warning notices for breaches identified to Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Receiving and acting on complaints) and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). The practice was placed into special measures following this visit. The full comprehensive report following the inspection in April 2017 can be found on our website here: http://www.cqc.org.uk/location/1-586401697.

We then undertook a follow up focused inspection of Daneshouse Medical Centre on 22 August 2017. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice had addressed concerns identified in the warning notices issued.

We undertook a further announced comprehensive inspection of Daneshouse Medical Centre on 1 December 2017. This inspection was carried out following the period of special measures to ensure further improvements had been made and to assess whether the practice could come out of special measures.

Our key findings were as follows:

  • The practice had improved its systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice documented investigations resulting from them and improved their processes.

  • Clinicians were aware of evidence- based guidelines.

  • Audits had been undertaken, however these were single cycle and changes made as a result had not yet been monitored for effectiveness.

  • The practice had improved its performance against the national Quality and Outcomes Framework (QOF) compared to the previous year (QOF is a system intended to improve the quality of general practice and reward good practice).

  • Improvements had been made to how complaints were managed and handled, although we did find an example where the practice’s response had not adhered to its own complaints policy.

  • Managerial oversight of staff training had improved, and there was a more systematic approach to staff appraisals. However, there were gaps in documentation relating to some clinical role-specific training.

  • Practice policy and procedure documents had been updated to make them practice specific, although we were not fully assured they were all sufficiently embedded to ensure they were adequately followed.

  • Patients continued to find the appointment system challenging and some reported that they were not always able to access care when they needed it.

  • Patients we spoke with were positive about their interactions with staff and said they were treated with compassion and dignity. However, results from the national GP patient survey continued to show patients rated the practice lower than others for many aspects of care.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

In addition the provider should:

  • Document a formal risk assessment for emergency medicines held on site.

  • Document an action plan following completion of infection prevention and control audits to facilitate improvements being made in a timely manner.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 9 February 2018

Effective

Requires improvement

Updated 9 February 2018

Caring

Requires improvement

Updated 9 February 2018

Responsive

Requires improvement

Updated 9 February 2018

Well-led

Requires improvement

Updated 9 February 2018

Checks on specific services

Older people

Requires improvement

Updated 9 February 2018

People with long term conditions

Requires improvement

Updated 9 February 2018

Families, children and young people

Requires improvement

Updated 9 February 2018

Working age people (including those recently retired and students)

Requires improvement

Updated 9 February 2018

People whose circumstances may make them vulnerable

Requires improvement

Updated 9 February 2018

People experiencing poor mental health (including people with dementia)

Requires improvement

Updated 9 February 2018