Background to this inspection
Updated
12 December 2018
The practice is comprised of the Danbury location and two branch sites, Mountbatten House surgery, in North Springfield, and Moulsham Lodge Surgery Chelmsford. The Practice provides primary care services to approximately 25,304 patients in the Danbury and Chelmsford surrounding areas of Essex. The Practice can offer a dispensing service to patients who live more than one mile (1.6km) from their nearest pharmacy. We inspected the Danbury, and Moulsham Lodge locations on the day of inspection. All sites are registered for the following regulated activities:
- Treatment of disease, disorder or injury.
- Surgical procedures.
- Family planning.
- Diagnostic and screening procedures.
- Maternity and midwifery services.
The practice has seven female and five male GPS. They also have regular locum GPs to support the clinical team. There is a managing partner, a business manager, two practice managers, a reception manager, and a team of administrative staff and receptionists across the three locations. A team of six dispensers is supported by a dispensary manager. There is one clinical prescribing pharmacist, two nurse practitioners, nine practice nurses, one health practitioner, and three healthcare assistants.
The practice holds a General Medical Services contract. The practice is a training practice and has four GP registrars (doctors training to become GPs) active at the time of our inspection. The practice is also a research Practice and was participating with research studies at the time of our inspection.
Appointments can be booked in advance with GPs and nurses. Urgent appointments are available for people that need them, as well as telephone appointments. Online appointments are available to book in advance. Patients can be seen at any of the practice sites. Telephone triage is undertaken by GPs.
Danbury Practice
Monday 08:00 - 20:00
Tuesday 08:00 - 18:30
Wednesday 08:00 - 18:30
Thursday 08:00 - 18:30
Friday 07:00 - 18:30
Weekend closed
Mountbatten House surgery
Monday 08:00 - 18:30
Tuesday 08:00 - 18:30
Wednesday 08:00 - 18:30
Thursday 08:00 - 18:30
Friday 08:00 - 18:30
Weekend closed
Moulsham Lodge
Monday 08:00 - 12:30 13:30 - 18:30
Tuesday 08:00 - 12:30 13:30 - 18:30
Wednesday 08:00 - 12:30 13:30 - 20:30
Thursday 08:00 - 12:30 13:30 - 18:30
Friday 08:00 - 12:30 13:30 - 18:30
Weekend closed
When the practice locations are closed patients can use the out of hour’s service provided by Care UK. Patients can also access advice via the NHS 111 service.
The most recent data available from Public Health England showed the practice has a lower percentage of patients aged 0 to 9 and 20 to 44 compared with the national average. Income deprivation affecting children is 8%, which is lower than the CCG average of 14% and the national average of 20%. Income deprivation affecting older people is 7%, which is lower than the CCG average of 12% and national average of 16%. Life expectancy for patients at the practice is 82 years for males and 85 years for females; this is above the national expectancy of 79 years and 83 years respectively.
Updated
12 December 2018
This practice is rated as Good overall. (Previous rating September 2017 – Requires Improvement).
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Requires improvement
Are services well-led? - Good
We carried out an announced comprehensive inspection at Danbury Medical Centre on 30 October 2018 and followed up on breaches of regulations found during the previous inspection.
At this inspection we found:
- There was a clear leadership structure and staff felt supported by management. The practice ensured that communication across the practice sites was clear and defined.
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
- There were clear systems to manage risk so that safety incidents were less likely to happen.
- When incidents did happen, the practice learned from them and improved their processes. Incidents were routinely reviewed and analysed to ensure occurrences were not repeated.
- The practice audited and reviewed the effectiveness and appropriateness of the care it provided. Audits showed this was to ensure care and treatment was provided according to evidence-based guidelines.
- The Danbury location dispensed medicines to patients. The arrangements for managing medicines, including emergency medicines and vaccines kept patients safe.
- We reviewed recruitment procedures undertaken prior to employment and found staff files viewed were complete and accurate.
- Information about services and how to complain was available. Improvements were made to the quality of care from the systems in place to learn from the lessons gained from concerns and complaints. These were shared with staff and stakeholders.
- We observed the two locations we inspected to be tidy and generally clean.
- Patients we spoke with said they did not always find it easy to make an appointment with a named GP however, there was continuity of care, and urgent appointments were available the same day.
- Patient satisfaction in the national GP patient survey was low in several areas. The practice carried out their own survey using questions from the national survey to understand whether changes being made were having a positive effect.
- We were told staff treated patients with compassion, kindness, dignity and respect.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
- Increase existing efforts to identify patients that are carers to ensure they are provided the support needed to maintain their health and caring role.
- Continue to monitor patients with diabetes and hypertension to ensure that appropriate reviews are undertaken and performance in this area is maintained.
- Continue to monitor and improve patient satisfaction as identified in the national GP patient survey published in August 2018.
Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.