The Care Quality Commission
  • Doctor
  • GP practice

Dormers Wells Medical Centre

Overall: Requires improvement read more about inspection ratings

Dormers Well Medical Centre, 143 Burns Avenue, Southall, Middlesex, UB1 2LU (020) 8571 0078

Provided and run by:
Dormers Wells Medical Centre

All Inspections

5 July 2023

During a routine inspection

We carried out an announced comprehensive inspection at Dormers Wells Medical Centre on 21 June 2023 and 5 July 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 23 January 2018 the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dormers Wells Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. We inspected all five key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

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 found that:

  • The provider had some systems and process in place to provide safe care and protect patients. However these were not always followed in practice. In particular, regarding the management of safety alerts and management of some high risk medicines.
  • The provider was aware of current guidance and standards for the care of patients diagnosed with a long term condition, however these guidelines were not always followed in practice.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed mostly promoted the delivery of high-quality, person-centred care.

We found one breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

Whilst these were not breaches of the regulations, the provider should:

  • Improve the identification of patients at risk of safeguarding concerns to include family members where appropriate.
  • Improve the recording of fire drills to ensure sufficient detail and consistency.
  • Take action to improve the results of the national GP patient survey and uptake of childhood immunisations and cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

23 January 2018

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dormers Wells Medical Centre on 4 May 2017. The overall rating for the practice was good. However, within the key question of safe areas were identified as 'requires improvement' as the practice was not meeting the legislation for providing safe care and treatment. The practice was issued a requirement notice under Regulation 12, safe care and treatment. The full comprehensive inspection on 4 May 2017 can be found by selecting the ‘all reports’ link for the Dormers Wells Medical Centre on our website at www.cqc.org.uk.

This inspection was a focused follow-up inspection carried out on 23 January 2018 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified at our previous inspection on 4 May 2017. This report covers our findings in relation to those requirements and also any additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings are as follows:

  • The practice had implemented an effective system to monitor patients on high risk medicines.

In addition improvements had been made in the following areas we had recommended:

  • The practice had implemented a process to act on patient safety and medicine alerts where relevant to general practice patients.
  • The practice had taken steps to improve patient satisfaction with access to the service by increasing the number of appointments available.
  • The practice had improved on the identification and support of patients who were also carers.
  • The practice had implemented a program of quality improvement and they had developed a strategy to deliver the practice vision.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dormers Wells Medical Centre on 15 March 2016. The practice was rated as good for providing effective, caring and responsive services, and requires improvement for providing safe and well-led services. The overall rating for the practice was requires improvement. We issued two requirement notices to the provider in respect of safe care and treatment and fit and proper persons employed.

The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Dormers Wells Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive follow up inspection on 4 May 2017 to check that action had been taken to comply with legal requirements and assess what improvements had been made. We found improvements had been made however further improvement was necessary in relation to providing safe services. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety. However, we found shortfalls with high risk medicine monitoring and acting on national patient safety alerts.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found they could make an appointment with a named GP in a reasonable time and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

  • Implement an effective system to monitor patients on high risk medicines.

In addition the provider should:

  • Implement a process to act on patient safety alerts when relevant to general practice patients.
  • Continue to monitor and improve patient satisfaction with access to the service.
  • Identify and support more patients who are also carers.
  • Develop a detailed strategy to deliver the practice vision.
  • Implement a program of quality improvement to include clinical audit to improve patient outcomes.
  • Consider ways to improve QOF exception reporting to bring in line with local and national figures.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

15 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 8.30am on 15 March 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.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks, staff training, medicine management and fire safety.
  • Data showed patient outcomes were comparable to the local and national averages. Although some audits had been carried out, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review.
  • The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

  • Ensure the monitoring of vaccine fridge temperatures is carried out in accordance with Public Health England guidance.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure Disclosure and Barring Services (DBS) checks are completed for non-clinical staff who act as chaperones or carry out risk assessments to mitigate the risk.
  • Ensure staff training is up to date and relevant particular in relation to chaperoning and safeguarding.
  • Ensure there is a system to monitor the use of prescription pads.
  • Ensure the risks associated with fire are assessed.
  • Ensure a locum induction pack containing all the necessary information for locums to work safely at the practice is made available.

In addition the provider should:

  • Develop a robust strategy to deliver the practices vision and monitor progress
  • Review and update policies, procedures and guidance.
  • Implement a programme of clinical audits and re-audits to drive improvement in patient outcomes.
  • Consider ways to identify and support more carers of patients in the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice