Archived: DMC Church View Practice

We carried out an announced inspection at DMC Church View Practice. We conducted clinical searches (remote review of patient records) on 10 November 2021 and visited the practice on 16 November 2021 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Requesting evidence from the provider
• A site visit.

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.

Our findings

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? - Good

Are services responsive? – Good

Are services well-led? – Inadequate

We rated the practice as Requires Improvement for providing safe services because:

• The provider did not always act on the issues identified in infection prevention and control audits.
• There was not an effective approach to managing staff absences and busy periods.
• Blank prescriptions were not always kept securely and not monitored in line with national guidance.
• The provider could not always demonstrate the prescribing competence of non-medical prescribers.
• Vaccines were not appropriately stored.

We rated the practice as Requires Improvement for providing effective services because:

• Some quality improvement activity did not contain relevant information for the practice or a date of when completed.
• Not all staff had protected time for learning and development.
• The provider was unable to provide evidence that new staff had received appropriate induction for their role.
• The provider could not always demonstrate how they assured the competence of staff.

We rated the practice as Good for providing caring services because:

• Staff helped patients to be involved in decisions about care and treatment.
• Interpretation services were available.
• The provider respected patients’ privacy and dignity.
• We saw that staff were respectful and polite when dealing with patients and maintained confidentiality.

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

• The provider understood the needs of the local population and delivered services to help meet patient needs.
• The provider made reasonable adjustments when patients found it hard to access services.
• The provider offered a range of appointment types to suit different needs.
• Patient feedback collected via the GP patient survey was above the local and national averages.
• Complaints were listened to as well as responded to and used to improve the quality of care.

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

• Leaders were not visible and accessible.
• The provider’s culture and strategy did not effectively support high quality sustainable care.
• The provider’s processes for managing risks, issues and performance were not effective.
• There were not sufficient numbers of suitably qualified, competent, skilled and experienced persons.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The provider should:

• Review medical equipment and ensure spare defibrillator pads are available.
• Continue to analyse incidents and near misses and consider how processes can be improved as a result.
• Review do not attempt cardiopulmonary resuscitation (DNACPR) forms to ensure they are accessible to all.

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