We carried out an announced comprehensive inspection at Dormers Wells Medical Centre on 21 June 2023 and 5 July 2023. Overall, the practice is rated as requires improvement.
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 23 January 2018 the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dormers Wells Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities. We inspected all five key questions.
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.
- 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.
We found that:
- The provider had some systems and process in place to provide safe care and protect patients. However these were not always followed in practice. In particular, regarding the management of safety alerts and management of some high risk medicines.
- The provider was aware of current guidance and standards for the care of patients diagnosed with a long term condition, however these guidelines were not always followed in practice.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The way the practice was led and managed mostly promoted the delivery of high-quality, person-centred care.
We found one breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
Whilst these were not breaches of the regulations, the provider should:
- Improve the identification of patients at risk of safeguarding concerns to include family members where appropriate.
- Improve the recording of fire drills to ensure sufficient detail and consistency.
- Take action to improve the results of the national GP patient survey and uptake of childhood immunisations and cervical screening.
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