16 May 2023
During an inspection looking at part of the service
We carried out an announced focussed inspection at Dashwood Medical centre on 16 May 2023. The practice was not rated as a result of this inspection.
Following our inspection on 23 November 2022, the practice was rated as inadequate overall as well as for providing safe and well-led services, requires improvement for providing effective and responsive services and good for providing caring services. They were placed into Special Measures. Breaches in regulation were found and Warning Notices for Regulation 12 and Regulation 17 were issued.
The full report for the November 2022 inspection can be found by selecting the ‘all reports’ link for Dashwood Medical Centre on our website at www.cqc.org.uk.
Why we carried out this inspection
We carried out this inspection on 16 May 2023 to confirm that the practice had met the legal requirements as stated in the Warning Notices issued after the 23 November 2022 inspection. This report covers findings in relation to those requirements and was not rated.
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.
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.
This inspection did not affect the provider’s rating which remains inadequate.
Our findings
- Improvements to the practice’s systems, practices and processes were insufficient and did not always keep people safe and safeguarded from abuse.
- The provider had made improvements to systems and processes to help maintain appropriate standards of cleanliness and hygiene. However, some infection prevention and control (IPC) issues were ongoing and had not been managed in a timely manner.
- Improvements to the assessment, monitoring and management of risks to patients, staff and visitors had been made. However, some improvements were still ongoing.
- Staff did not always have access to the information they needed to deliver safe care and treatment.
- Improvements to the arrangements for managing medicines were insufficient and placed patients at continued risk of harm.
- The provider had made improvements to the management of significant events. However, systems for dealing with safety alerts were still not effective.
- Some patients’ needs were still not always assessed and care and treatment was not always delivered in line with current legislation and standards.
- All staff were still not up to date with essential training and did not have access to regular appraisals.
- Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms were still not being completed in line with legislation and guidance.
- Complaints were investigated and responded to in a timely manner. However, we could not find evidence to show learning from complaints was being shared with relevant staff.
- Leaders had not taken sufficient action on all required improvements to quality, safety and performance.
- The provider was able to demonstrate compliance with the duty of candour.
- Improvements had been made to the management of backlogs of laboratory results and outstanding documents that required action. However, management of tasks on the practice computer system as well as management of test requests was insufficient.
- Improvements to processes for managing risks, issues and performance were insufficient.
- Improvements were required regarding evidence of systems and processes for learning, continuous improvement, and innovation.
We found there continues to be breaches of regulations. The provider must:
- 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.
The areas where the provider should make improvements are:
- Take action to ensure there is a completion date in the infection prevention and control action plan in relation to replacing the carpeted areas of the practice.
- Take action to ensure the keypad lock to the reception area is in use.
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