The Care Quality Commission
  • Doctor
  • GP practice

Horsmans Place Partnership Also known as Horsmans Place Surgery

Overall: Good read more about inspection ratings

Horsmans Place Surgery, Instone Road, Dartford, Kent, DA1 2JP (01322) 299790

Provided and run by:
Horsmans Place Partnership

All Inspections

During an assessment under our new approach

Date of Assessment: 30 June 2026. Horsmans Place Partnership is a GP service and delivers services to approximately 9,590 people under a contract held with NHS England. The National General Practice Profiles states that the ethnic make-up of the service area is 73% White, 11% Asian, 10% Black, 3% Mixed and 2% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the service population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

The purpose of the assessment was to follow up on the previous inspection, during which the GP service was rated Requires Improvement for providing Responsive services.

Since the last inspection on 6 April 2023, the service had made improvements. We found the service had improved telephone access and staff reported receiving positive feedback from people about these improvements.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

6 April 2023

During a routine inspection

We carried out an announced comprehensive inspection at Horsmans Place Partnership on 6 April 2023. Overall, the practice is rated as good.

Safe - good

Effective – good

Caring - good

Responsive - requires improvement

Well-led - good

Following our previous inspection on 17 May 2022 the practice was rated Inadequate overall and for providing safe and well-led services, rated Requires Improvement for providing effective and responsive services, and rated Good for providing caring services. The practice was rated Inadequate overall and placed into special measures as a result of this inspection. The provider was issued Warning Notices for breaches of Regulation 12 - Safe care and treatment and Regulation 17 - Good governance.

We carried out an announced follow up inspection on 20 October 2022, to check progress against the requirements of the Warning Notices issued and found full compliance had been achieved. However, breaches of Regulation 12 – Safe care and treatment were identified. The practice was not rated as a result of this inspection and the rating of Inadequate awarded to the practice following our full comprehensive inspection on 17 May 2022 remained unchanged.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Horsmans Place Partnership on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from our previous inspection.

This was a comprehensive inspection to review the following domains:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led

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.

Our findings

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 practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The provider carried out quality improvement activity.
  • Staff worked together and with other organisations to deliver effective care and treatment.
  • Staff helped patients to be involved in decisions about care and treatment.
  • Patients experienced difficulty accessing the practice by telephone.
  • The practice had taken action to address the issues regarding access. However, the provider had not yet collected patient feedback to demonstrate the effectiveness of the action taken.
  • Leaders had taken action to ensure the quality, safety and performance of the service.
  • There were clear systems to support good governance.
  • The practice had processes for managing issues, risks and performance.

Whilst we found no breaches of regulations, the provider should:

  • Continue with their action plans to; ensure all documents and tasks are managed in a timely way and marked as complete when actioned; reduce prescriptions of benzodiazepines and Z drugs; manage all patients with asthma in line with best practice guidance; monitor and improve the uptake of childhood immunisations and cervical cancer screening; monitor the actions taken to improve access, including the use of patient feedback exercises.
  • Take action to ensure the temperature of water outlets are within recommended ranges.
  • Provide up-to-date information regarding the patient participation group on the practice website.
  • Maintain the changes made to ensure staff areas are not accessible to patients or visitors.
  • Take effective action to identify a larger proportion of carers in the patient list.

This service was placed in special measures following our inspection on 17 May 2022. The practice has made significant improvements and is now rated Good overall and for providing safe, effective, caring and well-led services.The practice is rated Requires Improvement for providing responsive services. I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service. The service will be kept under review and will be inspected within 12 months to ensure improvements are sustained.

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.

20 October 2022

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Horsmans Place Partnership on 17 May 2022. Overall, the practice was rated as Inadequate and the practice was placed into Special Measures. Breaches in regulation were found and Warning Notices for Regulation 12 and Regulation 17 were issued.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Horsmans Place Partnership on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection on 20 October 2022 to confirm that the practice had met the legal requirements as stated in the Warning Notices issued after the 17 May 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:

  • 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.

Our findings

The practice was not rated as a consequence of this inspection.

Although the practice had taken action to address the requirements of the Regulation 12 Warning Notice which relates to safe care and treatment, we found that the practice was still failing to provide care and treatment in a safe way. In particular in relation to the following :

  • Patients prescribed high-risk medicines had not always received the required monitoring.
  • Patients with long term conditions had not always received the required monitoring. For example, patients with hypothyroidism, diabetic retinopathy and asthma.
  • Patients with potential missed diagnoses of diabetes and chronic kidney disease had not always received the required monitoring.
  • Patients prescribed 10 or more prescriptions of benzodiazepines or Z drugs did not always have a documented discussion of the risk of addiction. (Benzodiazepines are medicines that may be used as a short-term treatment for severe anxiety, Z drugs are medicines that may be used as a short-term treatment of severe insomnia).
  • Fire and legionella risk assessments did not contain details of action taken by the provider to mitigate the risks identified.

However, the practice had met the Regulation 12 Warning Notice by:

  • Following best practice guidance for the monitoring of patients prescribed lithium and for action taken on safety alerts.
  • Following best practice guidance for the monitoring of some patients; prescribed methotrexate; requiring thyroid function monitoring tests; with potential missed diagnosis of diabetes; and with potential missed diagnosis of chronic kidney disease.

The practice had met the Regulation 17 Warning Notice by:

  • Completing clinical supervision audits and providing guidance to staff on clinical supervision.
  • Completing appropriate recruitment checks and Disclosure and Barring Service (DBS) checks for staff employed at the practice.
  • Providing training in the management and identification of sepsis for staff employed by the practice.
  • Holding regular meetings that were minuted and included discussions of complaints and significant events.
  • Reviewing and updating safeguarding policies so that they contain information relevant to the practice.

However, we also found that:

  • The practice did not always have clear and effective processes for managing risks, issues and performance.

We found one breach of regulation. The provider must:

  • Ensure care and treatment is provided in a safe way to patients

The areas where the provider should make improvements are:

  • Continue to gather information on the immunisation status of staff employed by the practice.
  • Ensure there is an infection prevention and control policy, that is relevant to the practice and contains up-to-date information, available for guidance.

Please refer to the detailed report and the evidence table for further information

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

17 May 2022

During a routine inspection

We carried out an announced inspection at Horsmans Place Partnership on 17 May 2022. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive – Requires improvement

Well-led – Inadequate

Following our previous inspection on 28 September 2016, 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 Horsmans Place Partnership on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to review the following domains:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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 Inadequate overall

We found that:

  • Safeguarding policies had not recently been reviewed and updated.
  • Disclosure and Barring Service (DBS) checks had not always been seen by the practice.
  • Recruitment checks were not always carried out in accordance with regulations and practice policy.
  • Staff vaccination was not always maintained in line with current Public Health England guidance.
  • Risks to patients, staff and visitors were not always assessed, monitored or managed effectively.
  • There was no record that reception staff had received training in the identification of ‘red flag’ signs or symptoms or sepsis in patients.
  • The arrangements for managing medicines did not always keep patients safe.
  • There was no formal clinical supervision or audit of the prescribing/consultations of non-medical prescribers
  • Learning from significant events and complaints was not always shared with relevant staff.
  • Systems for managing safety alerts were not always effective.
  • Patients’ needs were assessed, but care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Patients with long-term conditions were not always receiving relevant reviews that included all elements necessary in line with current best practice guidance and not all patient reviews were followed up where necessary in a timely manner.
  • The practice carried out quality improvement activity, but there was not always evidence that they had implemented and followed up on the recommended changes.
  • Staff worked together and with other organisations to deliver care and treatment which was not always effective.
  • Staff treated patients and colleagues with kindness, respect and compassion.
  • Staff helped patients to be involved in decisions about care and treatment.
  • The practice respected patients’ privacy and dignity.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • There was compassionate leadership at all levels. However, leaders were not aware of all required improvements to quality, safety and performance.
  • Improvements were required to the processes and systems that supported good governance and management.
  • The practice’s processes for managing risks, issues and performance were not always effective.
  • Processes to manage current and future performance were not sufficiently effective.
  • The policies and protocols for managing medicines did not always keep patients safe.

We found breaches of regulations. The provider must:

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

We took enforcement action and issued warning notices against the provider in relation to Regulation 12(1)(2) Safe care and treatment and Regulation 17(1)(2) Good governance.

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

The provider should:

  • Ensure that household members of ‘at risk’ children are recorded as alerts on the clinical system.
  • Ensure that a health and safety notice is displayed in the building and consider testing fire alarms more frequently.
  • Ensure that Infection Prevention and Control (IPC) training is appropriate to the staff member’s role.
  • Ensure that specimens are stored in an appropriate refrigerator overnight.
  • Continue to investigate ways to improve uptake of childhood immunisations, cervical cancer screening and breast cancer screening.
  • Engage in regular feedback and monitoring exercises with patients and staff.
  • Consider redistribution of staff to increase those answering phones at busy times.
  • Include the date and names of attendees when recording minutes.
  • Consider ways to identify more carers and young carers.
  • Encourage reforming the Patient Participation Group and appoint a Freedom to Speak Up Guardian.

I am placing this service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

28 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Horsmans Place Partnership on 28 September 2016. 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 an effective system for reporting and recording significant events, and learning from these was discussed, shared and embedded at the practice.
  • Risks to patients were assessed and well managed, including an infection control audit with identified actions and the date these were achieved.
  • Medicines were well managed and organised within the practice.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained and had received updates to training to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • The practice provided a personal list system for patients, which meant that patients had their own GP who would see them unless they required an emergency appointment.

  • Patients said they were treated with compassion, dignity and respect, and were involved in their care and decisions about their treatment.

  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns, and the practice was open and transparent in responding to these.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However, the response to the GP patient survey rated the practice lower than the CCG and national averages for being able to get through on the telephone to make an appointment. The practice had an action plan to address this.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. It had been refurbished to increase accessibility for patients with reduced mobility and for those with babies and small children.

  • 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.

  • The provider was aware of and complied with the requirements of the duty of candour.
  • The patient participation group (PPG) was active at the practice and improvements were made as a result of their input, reflecting the patient voice.

The areas where the provider should make improvement are:

  • Continue to address and take action on areas below the local and national average as identified by the GP Patient Survey.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice