The Care Quality Commission
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  • GP practice

Archived: Dr Davis's Medical Practice Also known as Leicester Road Medical Centre

Overall: Requires improvement read more about inspection ratings

53 Leicester Road, Salford, Lancashire, M7 4AS (0161) 708 9992

Provided and run by:
Dr Davis's Medical Practice

All Inspections

7 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Dr Wayne Sefton Davis on 7th July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be good for providing safe, responsive and caring services. It still required improvement for providing effective and well led services.

We found that many improvements had been made since the previous inspection of October 2014 when the practice had been rated as Inadequate. We also found areas where improvement was still required. The provider was aware of the further work that needed to be completed.

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

  • Improvements had been secured since the previous inspection.
  • Policies and procedures had been developed and reviewed and made available to staff.
  • Infection control was more effectively managed.
  • Staff recruitment procedures were more robust.
  • Medicines were more effectively managed.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • Staff were aware of their responsibilities to raise concerns and felt confident to do this.

However there were areas of practice where the provider must still make improvements.

Importantly the provider must

  • Ensure that staff receive training appropriate to their roles and responsibilities..
  • Ensure that governance systems are further developed in order to improve outcomes for patients.

The provider also should

  • Develop a more focused Business Continuity Plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Leicester Road medical practice was inspected on the 22 October 2014. This was a comprehensive inspection. This means we reviewed the provider in relation to the five key questions leading to a rating on each on a four point rating scale. We assessed all six of the population groups and the inspection took place at the same time as we inspected a number of practices in the area overseen by Salford Clinical Commissioning Group (CCG). The named GP had temporarily been unable to practice since February 2014. A part time GP was providing the service supported by locum GP cover.

Overall we rated Leicester Road Medical Practice as being inadequate.

Specifically, we found the practice inadequate for providing safe and effective services and being well led. It was also inadequate for providing services for the six population groups that we assess. Improvements were also required for providing responsive and caring services.

Our key findings were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control practice had not been taken.
  • Staff were not consistently clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.
  • There was insufficient assurance to demonstrate people received effective care and treatment. For example mandatory training was not provided to staff.
  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments and that it was very difficult to get through the practice when phoning to make an appointment.
  • The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

  • Take action to prevent the risk of infection.
  • Take action to more effectively manage medications.
  • Take action to ensure that people who use the service are protected by operating effective recruitment and selection procedures.
  • Take action to ensure that persons employed are suitably supported and trained to perform their role.
  • Complete and submit a Statement of Purpose.
  • Take action to assess and monitor the quality of its service.

The areas where the provider should make improvement are:

  • Improve team working and ensure staff are aware of lead roles, responsibilities and practice vision.
  • Record minor complaints.
  • Access and record results from blood tests carried out on patients.
  • Review medical equipment and ensure all damaged and un-calibrated equipment is removed.
  • Ensure whistleblowing policy contains all relevant information and is available to staff.
  • Ensure vulnerable patients are identified and relevant information is available to staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 March 2014

During an inspection looking at part of the service

We inspected this practice to follow up actions taken in respect of compliance actions made at the last inspection in November 2013 and in relation to concerns raised about the arrangements for safeguarding referrals.

The principle GP was not working in any clinical capacity however he was undertaking the requirements as the registered provider and registered manager.

We found improvements had been made to gather people's views and experiences in the way the service was provided and delivered in relation to their care. Since the last inspection the practice had taken action to commence a patient participation group (PPG) which was now in the very early stages of implementation.

We found staff had access to contact details for both child protection and adult safeguarding teams. They were able to describe the appropriate actions they would take if there were any safeguarding concerns.

We saw the service had made improvements to ensure effective infection control practices were in place. Areas still to be addressed included staff training and recording of staff immunisations.

The provider had made improvements to monitor the quality of the service and to seek the views of people using the service. The practice had a range of policies and procedures for staff to access, to support the safe management of the service. We saw staff meetings were held and minutes were kept.

5 November 2013

During an inspection in response to concerns

During our inspection we spoke with six patients who used the service and we received some positive feedback. One patient told us: "The staff and the doctors listen to me and are professional" and "They are great with results. I even get a print out of my blood results which I like'. Patients told us they were satisfied with the appointment system and, when necessary, were given an appointment on the same day.

The practice did not have a system in place for patients to be involved in the decisions made regarding the practice.

The practice had an effective recording system to record the consultations patients had with the GP and the actions taken to provide appropriate care and treatment.

Patients were not protected from the risk of infection because appropriate guidance had not been followed and there were not effective systems in place to reduce the risk and spread of infection.

We had concerns in two areas of practice that the principal GP did not have appropriate medicine management procedures in place and was working outside his knowledge/practice.

The principle GP did not have an effective system in place for monitoring the quality of the service or to seek the views of patients using the service. There was no practice leaflet or information about how to raise a complaint or concern on display in the service. This meant that the provider did not bring the complaints system to the attention of all people who use the service in a suitable format.