• Doctor
  • Independent doctor

Archived: Derby Family Medical Centre

Overall: Requires improvement read more about inspection ratings

1 Hastings Street, Derby, Derbyshire, DE23 6QQ (01332) 773243

Provided and run by:
Al-Quddoos Limited

All Inspections

14 March 2020

During a routine inspection

  • The service had previously been inspected in March 2018 and was found to be providing services in accordance with relevant regulations. At that time independent providers of regulated activities were not rated by the Care Quality Commission. At the previous inspection the provider was informed that they should consider the following improvements;

    • Develop an appraisal system to support the development of staff.
    • Improve the recording of minutes of meetings undertaken with staff.
    • Develop the provision of information in other languages for patients who may have limited knowledge of the English language.

    The key questions are rated as:

    Are services safe? – Requires improvement

    Are services effective? – Good

    Are services caring? – Good

    Are services responsive? – Good

    Are services well-led? – Requires improvement

    We carried out an announced comprehensive inspection at Derby Family Medical Centre as part of our inspection programme.

    The single practitioner and the service manager are the registered managers and leaders of this service. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

    We collected 13 comment cards that had been completed by patients at the previous week’s clinics. All comment cards were positive about the service and the manner in which patients were treated.

    Our key findings were :

    • The provider was able to demonstrate comprehensive safeguarding systems were in place and recruitment procedures kept patients safe. We found concerns in relation to systems in place to manage risk to patients in that they were not working effectively.
    The provider delivered services within guidelines and used up to date methodology. The provider engaged in clinical audits to ensure that patients were experiencing positive outcomes.
  • The service offered three separate opportunities for patients to feedback in a structured way as well as considering free text and verbal feedback as well. Feedback we received was generally positive about access to the service and about how they felt they were treated by staff.
  • The provider was unable to demonstrate that all appropriate systems or processes had been established or were working as intended to support the safety of staff or service users. We found that the provider had acted to ensure information was provided to patients in languages other than English, according to the needs of their population. They were also able to demonstrate that they had recorded minutes of meetings held with staff but could not demonstrate that they had taken any action taken to address the lack of appraisals to develop and support staff, which was a should from the previous report.

The areas where the provider must make improvements as they are in breach of regulations are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Establish a system to ensure patient’s GPs are directly communicated with by the provider.
  • Develop an appraisal system and embed it into the development and support for all staff.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

17/03/2018

During a routine inspection

We carried out an announced comprehensive inspection on 17 March 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Our key findings were:

  • The provider had systems in place to manage incidents and significant events.
  • The service had clear systems to keep patients safe and safeguarded from abuse. There was an effective system in place to obtain consent from persons with parental responsibility.
  • Risks to patients were assessed and managed. The service held emergency medicines and equipment.
  • Policies and procedures were in place to govern relevant areas and they were updated regularly.
  • The clinical lead assessed patients’ needs and delivered care in line with current evidence based guidance. There was evidence of clinical audits undertaken to improve outcomes for patients.
  • 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. A website for the clinic was under development in response to feedback about increasing awareness of the service in the community.
  • Written information was provided to the parents of patients detailing how to care for the patient following surgery.
  • The provider had good facilities and was well equipped to treat patients and meet their needs.
  • The provider actively sought feedback from patients through various methods and acted on the feedback to improve user experience.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

Some areas where the provider should consider improvements are:

  • Develop an appraisal system to support the development of staff.
  • Improve the recording of minutes of meetings undertaken with staff.
  • Develop the provision of information in other languages for patients who may have limited knowledge of the English language.