The Care Quality Commission
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Delamere Medical Practice

Overall: Outstanding read more about inspection ratings

Delamere Avenue, Stretford, Manchester, Greater Manchester, M32 0DF (0161) 864 0200

Provided and run by:
Delamere Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Delamere Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Delamere Medical Practice, you can give feedback on this service.

During an inspection looking at part of the service

We inspected Delamere Medical Practice as part of our inspection programme on 23 May 2018. At that time, we found two areas of outstanding practice and the practice was rated good overall. After our inspection there was a serious significant incident at the practice. Because of that incident a complete review of staffing, systems and processes was undertaken to ensure that safe care, specifically for vulnerable patients was improved.

The practice informed us of the significant events, what had occurred and why and the immediate actions they had taken to maintain safety.

We decided to undertake an early annual regulatory review of the practice to ensure that any further risk had been minimised. The information submitted to us during the review indicated that significant improvements had been made in all areas of the service.

We decided to undertake an inspection of this service following our annual review. The inspection looked at the following key questions, safe, effective, responsive and well- led. We did not look at caring at this inspection but the rating from the last inspection was good and that has been carried forward.

At this inspection on 2 October 2019 we rated the practice as outstanding. 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 Outstanding overall.

We rated the practice as outstanding for providing Safe and Well Led services because:

  • There was evidence that people were protected by a comprehensive safety system and a focus on openness, transparency and learning when things went wrong.
  • Systems took account of current best practice and the whole team was engaged in reviewing and improving safety and safeguarding systems.
  • People who used services were at the centre of safeguarding and were protected from discrimination.
  • There were innovative approaches to providing integrated person-centred care.
  • The practice had identified areas where there were gaps in provision locally and regionally and had taken steps to address them.
  • The culture of the practice and the way it was led and managed drove the delivery of high quality person-centred care.

We rated the practice as Good for effective and responsive services because:

  • People had good outcomes as they received effective care and treatment that met their needs.
  • Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care. However, the patient satisfaction survey did not reflect overall patient satisfaction.

We saw several areas of outstanding practice including:

  • The practice introduced an improved medicine review template because they found the standard template in the clinical system was not effective and did not reduce error. The new template pulled through the patient’s complete medical history, all prescribed medicines and questions that should be asked of the patient to ensure up to date guidelines were being consistently followed. The practice provided numerous examples where the new template had improved safe and appropriate prescribing. For example, it highlighted a patient with atrial fibrillation who was being under-dosed, a diabetic patient was needed to be referred back to secondary care services for review, a safeguarding incident that needed to be referred and an outpatient prescription request that needed to be questioned and clarified.
  • The practice had introduced several in-house services for patients of their own practice and also patients of the wider North Trafford community and patients in the whole of Trafford. Those services included dermatology and minor surgery. Waiting times for minor surgery in Trafford had reduced from six months to two weeks.
  • The practice introduced rigorous monitoring and maintenance of vulnerable patients and ensured that contact with those patients remained consistent when they were in crisis and reduced when they became stable.
  • The practice had a large cohort of patients with mental health conditions and it was identified that there was a gap in service provision for patients with conditions that did not meet secondary care services. They employed clinicians with expertise in mental health including a mental health nurse and a GP and now provided a step up/step down service and psychological interventions for those patients.

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

During a routine inspection

This practice is rated as Good overall. (Previous rating December 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Delamare Medical Practice on 23 May 2018 as part of our inspection programme.

  • The practice had 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.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw two areas of outstanding practice :

  • “ASK GINA”. This is a services that the practice has set up following a talk by Housing Options Services Trafford (HOST) during one of the CCG events attended by the practice manager. The service offered advice and assistance on housing related issues supporting patients with no fixed address and helping them to find temporary accommodation. The service was free, impartial and confidential. The practice manager set up their own service within the practice to signpost patients in need to HOST without jeopardising their dignity. A member of staff was released to spend a day with HOST so the practice could understand the type of requests that were received and then they set up a file with all contact numbers, services, local food banks and patient information leaflets. They then launched their ASK GINA service whereby patients in need of help could come to reception and simply ask for Gina who would then confidentially discuss options and services available to them.

  • The practice provided GP led educational evenings for patients to raise awareness on medical issues every three months. To date they had hosted three events with an uptake of around 30 patients. Discussions included COPD and asthma management, rescue packs, vaccines and inhaler techniques; Sepsis, discussing symptoms to look out for, speed of deterioration, what to do and treatment; and everything about audiology and the management of hearing loss.

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.

1 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Delamere Medical Practice on 1 December 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, when there were unintended or unexpected safety incidents, not all staff followed the same process to report them and lessons learned were not always communicated widely enough to support improvement.

  • Risks to patients were assessed and well managed.

  • Data showed some patient outcomes were low compared to the locality and nationally. However audits had been carried out, and we saw evidence that these audits were driving improvement in performance to improve patient outcomes.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on and the provider was aware of and complied with the requirements of the Duty of Candour.
  • Patients said they found it difficult to get through on the telephone and were not always able to make an appointment when they needed to. However all patients had a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. However, there was no information on the practice website or a practice leaflet about opening hours, appointment times, how to access an appointment, what clinics were offered or what to do when the practice was closed.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, privacy was compromised and long queues caused congestion at reception during busy times.

The areas where the provider should make improvement are:

  • Lessons learned were not always communicated widely enough to support improvement. The practice should continue to develop systems to improve feedback and communication between GPs, nursing, administration and reception staff.

  • Access at reception should be reviewed to alleviate congestion and increase patient confidentiality.

  • The practice website should be updated to include information about opening times, clinic availability and access for patients during and out of hours.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 October 2013

During a routine inspection

The practice had an up to date consent policy. All members of staff we spoke with understood the principles of obtaining consent, including issues relating to capacity.

The practice had a patient's charter in place and policies and procedures which gave up to date guidance for staff. Policies included dignity, chaperone and teenage confidentiality.

Patient told us: 'I always get seen when I need to and we have had a really good package of care for my son's on-going health needs.' 'I am always happy when I come, always get the right guidance.' "I haven't had a bad experience, it doesn't matter which GP I see. I once needed a home visit and I couldn't have asked for better."

Staff were able to demonstrate clear understanding of their roles and responsibility to safeguarding patients. One member of staff told us: 'Everybody's got a responsibility.'

All areas of the practice were clean, tidy and well maintained. The infection control policy clearly set out people's roles and responsibilities and requirement for staff to attend annual training.

The practice had a suggestion box in the reception area for patients to provide comments. Feedback was also sought from patients through an annual survey. We saw the results from the survey carried out in 2012 and were shown copies of the survey due to be carried out in 2013. Feedback from the 2012 survey was positive.