Archived: Dickens Place Surgery

We carried out an announced comprehensive inspection at Dickens Place Surgery on 27 September 2022. Overall, the practice is rated as good. This is the first inspection for this service.

The ratings for each key question

Safe - Good

Effective – Good

Caring – Good

Responsive - Good

Well-led – Good

Why we carried out this inspection

This inspection focused on:

• Safe, effective, caring, responsive and well-led services

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
• 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 have rated this practice as Good overall.

We found that:

• We found the monitoring of medicines and safety alerts were carried out in line with national guidance.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The practice had carried out a range of environmental risk assessments to ensure the safety of their staff and patients.
• The practice had safeguarding systems in place however safeguarding registers were not developed at the time of the inspection. Since the inspection, the practice had completed a safeguarding audit and introduced registers to highlight vulnerable patients.
• Although the practice had cold chain procedures in place, we found documentation was inconsistent. Since the inspection, the practice has reviewed and implemented changes to their procedures to ensure checks are completed in line with national guidance.
• The practice had engaged with local businesses to encourage the working age population to participate in national screening programs such as cervical screening.
• Patients received effective care and treatment that met their needs.
• We found a number of staff had not completed mandatory training. Since the inspection, the practice had reviewed their online training system and given staff time to complete the necessary training.
• We reviewed a number of staff files for clinical and non-clinical members of staff. We found that non-clinical staff members vaccinations were not noted in their files. Since the inspection, the practice had provided evidence of these checks.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Strengthen safeguarding systems.
• Strengthen systems to ensure staff training is completed.
• Improve system to monitor cold chain procedures in line with national guidance.
• Continue to update vaccination records for non-clinical members of staff.
• Continue to improve the uptake for cervical screening.
• Improve patient satisfaction as highlighted in data from the National GP Patient Survey.

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 Hospitals and Interim Chief Inspector of Primary Medical Services