All inspections: Dulwich Medical Centre

We carried out an announced comprehensive inspection at Dulwich Medical Centre on 13 July 2023. Overall, the practice is rated as Requires Improvement.

Safe - good.

Effective - requires improvement.

Caring – good.

Responsive – good.

Well-led - requires improvement.

Following our previous inspection on 22 September 2022, the practice was rated Requires Improvement overall and for providing safe, effective, caring and well-led services. The practice was rated Inadequate for providing responsive services. As a result of this inspection, the practice was placed into special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dulwich Medical Centre 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 have rated this practice as Requires Improvement.

We have rated the practice as Requires Improvement for providing effective services because:

Improvements were needed to the uptake of childhood immunisations and cervical cancer screening.
The practice could not demonstrate there was an induction programme for all new staff.

We have rated the practice as Requires Improvement for providing well-led services because:

There were not always clear and effective processes for managing risks, issues and performance. In particular, the practice had not identified and managed all risks relating to; staff immunisations; uptake of childhood immunisations; uptake of cervical cancer screening; patients prescribed rescue steroids; and the induction process for all new staff

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
There were clear systems in place to manage risks associated with; infection prevention and control; patient safety alerts; and significant events.
Staff had completed required training appropriate to their role.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Improvements were seen in the National GP patient survey scores and there was evidence the practice had acted in response to this feedback.
The practice had taken action to ensure patients could access care and treatment in a timely way.

We found one breach of regulation. The provider must:

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 so that; patients prescribed ACE inhibitors or Angiotensin II receptor blockers; and patients with hypothyroidism, receive monitoring in line with best practice guidance.
Complete and record an induction for each member of staff.

This service was placed in special measures following our inspection on 22 September 2022. The practice has made significant improvements and is now rated requires improvement overall and for providing effective and well-led services. The practice is rated good for providing safe, caring and 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

We carried out an announced comprehensive inspection at Dulwich Medical Centre. A remote clinical assessment was conducted on 20 September and a site visit was undertaken on 22 September 2022.

The practice is rated as Requires Improvement overall

Safe – Requires Improvement

Effective – Requires Improvement

Caring – Requires Improvement

Responsive – Inadequate

Well led – Requires Improvement

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

Why we carried out this inspection

This inspection was a comprehensive inspection as part of our risk-based approach to reviewing and inspecting services to check if the provider had addressed concerns highlighted following our previous focused inspection and to review the overall quality of care being provided.

How we carried out the inspection

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 aimed to enable 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:

Reviewing patient records to identify issues and clarify actions taken by the provider.
Requesting evidence from the provider.
A site visit where we undertook clinical searches on the practice’s patient records system and discussed our findings with the provider.

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.

Our previous inspection was a focused unrated inspection looking at the key questions safe, effective, and well led.

Our findings were:

Not all family members of children at risk or in need had alerts on their record and we found two children in need did not have alerts on their own records.
Clinical audits lacked evidence of quality improvement.
The issue previously identified related to risk assessments for staff with prior convictions being reflected in staff job descriptions had not been addressed. However, we were told on this inspection that the person in question’s job description was incorrect and therefore the original risk identified was never there.
The staff member who did not have hepatitis B vaccine was unable to provide evidence of vaccination. However, this staff member did not perform any procedures that carried a risk of infection from blood borne illness which meant that risk of contracting this disease was minimal.
Performance against targets for childhood immunisations and cervical screening were below local and national averages though the practice outlined action taken to improve uptake.
We found two dirty light cords in the practice. However, risk from this was mitigated by these being covered with a plastic cover which was cleaned regularly. All other issues related to infection control had been addressed.
The documentation for patients prescribed high risk medicines had improved with only some minor areas for improvement.

As a result of our findings at our previous inspection we decided to bring forward the planned comprehensive inspection of this location in order to fully assess the provider’s compliance with our regulations. At this inspection we found the following issues:

Clinical audits still lacked evidence of quality improvement.
The practice did not have recruitment and training documentation for locum staff.
The process for reporting significant events was unclear and the system for acting on patient safety alerts needed improvement.
Some areas of infection prevention and control had not been fully considered in the practice’s audit.
Patient feedback related to access and treatment were below local and national averages. The practice outlined actions taken to improve access at the surgery.
Performance against targets for childhood immunisations and cervical screening were still below local and national averages though the practice outlined action taken to improve uptake.
Governance and oversight arrangments in areas of risk and quality improvement were not consistently working well.

However we also found that:

The quality of clinical care provided was of a generally good standard.
Staff were positive about working at the service.
Leadership were aware of some of the practice’s challneges and were taking action to make improvements.

We found 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.
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment

I am placing this service in 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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

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

We carried out an announced inspection at Dulwich Medical Centre on 26 April 2022

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

Why we carried out this inspection

This inspection was a focused inspection as part of our risk-based approach to reviewing and inspecting services to check if the provider had complied with a warning notice issued for breaches of regulation 17 (Good Governance) issued at our last inspection on 21 September 2021.

How we carried out the inspection

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 aimed to enable 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:

Reviewing patient records to identify issues and clarify actions taken by the provider.
Requesting evidence from the provider.
A site visit where we undertook clinical searches on the practice’s patient records system and discussed our findings with the provider.

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.

Our previous inspection was a focused inspection looking at the key questions safe, effective, responsive and well led. We rated the practice as requires improvement for safe and effective, good for responsive and inadequate for well led. As a result of our findings we issued warning notices for regulation 17 because:

We found that some patients with asthma, diabetes and COPD were not receiving appropriate care and treatment
We found that there were issues with the documentation for some patients prescribed high risk medicines and a lack of documented counselling with patients on risks associated with taking one medicine.
Performance against targets for childhood immunisations and cervical screening were below local and national averages.
The families of children at risk or subject to safeguarding concerns did not have flags on their medical records
Criminal background checks highlighted previous convictions for staff and risk assessments did not take account of the responsibilities outlined in the staff member’s job description
One member of clinical staff was not vaccinated against Hepatitis B
Risks associated with infection control had not been properly assessed or mitigated.
The practice did not have a spare set of defibrillator pads
Blank prescriptions were not securely stored, and their use was not being monitored.
Patient Group Directions had not been filled in correctly.
There was a lack of documented action following breaches of the practice’s vaccine cold chain policy.
Clinical audits did not demonstrate quality improvement
The practice had not sought or acted on feedback from patients as they had not responded to reviews on NHS choices.

At this inspection we found the following issues:

Not all family members of children at risk or in need had alerts on their record and we found two children in need did not have alerts on their own records.
Clinical audits still lacked evidence of quality improvement
The issue related to risk assessments for staff with prior convictions being reflected in staff job descriptions had not been addressed. However, we were told on this inspection that the person in question’s job description was incorrect and therefore the original risk identified was never there.
The staff member who did not have hepatitis B vaccine was unable to provide evidence of vaccination. However, this staff member did not perform any procedures that carried a risk of infection from blood borne illness which meant that risk of contracting this disease was minimal.
Performance against targets for childhood immunisations and cervical screening were still below local and national averages though the practice outlined action taken to improve uptake.
We found two dirty light cords in the practice. However, risk from this was mitigated by these being covered with a plastic cover which was cleaned regularly. All other issues related to infection control had been addressed.
The documentation for patients prescribed high risk medicines had improved with only some minor areas for improvement.

However, the following improvements had also been made:

Patients with long term conditions whose records we reviewed were having appropriate care and treatment.
The practice had spare defibrillator pads.
Patient Group Directions we reviewed were all completed correctly.
Blank prescriptions were stored securely, and their use monitored.
Breaches of the vaccine cold chain were dealt with in line with the practice’s policy.
The practice had responded to feedback on NHS choices.

We found 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 provider should:

Continue to work to improve the uptake of screening and immunisations.
Review recruitment policies to ensure job descriptions are reflective of risk assessments undertaken for staff who have prior criminal convictions.
Review policies around staff vaccinations.
Act to further improve the documentation of care provided to those taking high risk medicines.

As a result of our findings we decided to bring forward the planned comprehensive inspection of this location in order to fully assess the provider’s compliance with our regulations.

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

We carried out an announced comprehensive inspection at Dulwich Medical Centre on 31 July 2019. The overall rating for the practice was Requires Improvement.

After our inspection in July 2019 the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced focussed inspection at short notice to the provider at Dulwich Medical Centre on 28 August 2020 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in July 2019. The practice was not rated as a result of this inspection. We found that the provider had not made sufficient improvement and issued a Warning Notice.

We carried out an announced focussed review at Dulwich Medical Centre on 14 April 2021 to confirm that the provider had taken action to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in August 2020. The practice was not rated as a result of this review. We found that the provider had made sufficient improvements and met the Warning Notice. However, breaches in regulations remained and a Requirement Notice was issued.

After our inspection in April 2021 the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

The full versions of the reports for the July 2019 and August 2020 inspections as well as the April 2021 review can be found by selecting the ‘all reports’ link for Dulwich Medical Centre on our website at www.cqc.org.uk.

Why we carried out this inspection:

We carried out an announced focussed inspection at Dulwich Medical Centre on 21 September 2021 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous review in April 2021. This report covers findings in relation to those requirements.

How we carried out the inspection:

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 in line with all data protection and information governance requirements.

This included:

Conducting staff interviews using the telephone / video conferencing.
Requesting evidence from the provider.
A short site visit.

Our judgement of the quality of care at this service is based 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.

Our findings:

This practice is now rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Inadequate

We rated the practice as Requires Improvement for providing safe services because:

The practice’s computer system did not alert staff of all family and other household members of children that were on the risk register.
Risks associated with employing staff that had convictions recorded on their Disclosure and Barring Service (DBS) check were not fully considered or mitigated.
Risk assessments failed to contain sufficient rationale for the lack of hepatitis B vaccination records for one member of clinical staff.
Appropriate standards of cleanliness and hygiene were not always met.
Risks to patients, staff and visitors were not always assessed, monitored or managed effectively.
Staff had the information they needed to deliver safe care and treatment.
Published results showed that the practice’s prescribing indicators were all either in line with or better than local Clinical Commissioning Group (CCG) and England averages.
Patient Group Directions (PGDs) had not been completed correctly and improvements were required to the management of high-risk medicines prescribing, blank prescription form management and vaccines management.
There were effective systems for recording and acting on significant events as well as managing safety alerts.

We rated the practice as Requires Improvement for providing effective services because:

Reviews of patients with long-term conditions did not always include all elements necessary in line with current best practice guidance and not all patient reviews that we looked at were followed up where necessary in a timely manner.
The pandemic had had a detrimental effect on the practice’s ability to deliver some care as well as treatment. However, performance relating to child immunisations and cervical screening required improvement.
Published results showed that the practice’s performance for the mental health indicators was either in line with or above local and national averages.
Not all staff had access to regular appraisals.
The practice obtained consent to care and treatment in line with legislation and guidance.

We rated the practice as Good for providing responsive services because:

The practice organised and delivered services to help meet patients’ needs.
People were able to access care and treatment in a timely way. However, improvements to GP patient survey satisfaction scores were required.
Complaints were listened as well as responded to and used to improve the quality of care.

We rated the practice as Inadequate for providing well-led services because:

The practice’s processes for managing risks, issues and performance were not always effective.
Some processes to manage current and future performance were not sufficiently effective. Improvements to care and treatment were required for some types of patient reviews as well as subsequent follow-up activities.
The practice was not able to meet the needs of children requiring childhood vaccinations and women who required cervical screening.
The practice engaged with the public, staff and external partners and was in the process of reinstating a patient participation group. However, most improvements in response to patient feedback were ongoing.
The practice had a vision to deliver high quality care and promote good outcomes for patients.
There were processes and systems to support good governance and management.
The provider had made improvements to clinical audit activities.

The areas where the provider must make improvements are:

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.
Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The areas where the provider should make improvements are:

Revise storage of substances hazardous to health so that they are stored safely and securely when not in use.
Continue with activities to recruit patients to the Patient Participation Group.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

We carried out an announced review of Dulwich Medical Centre on 30 March 2021 & 14 April 2021. This was an unrated review to consider whether the provider had taken sufficient action to address the breaches of regulation 17 outlined in the warning notice issued following our previous inspection undertaken on 28 August 2020.

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

Why we carried out this in review

This was a review of information undertaken without completing a site visit inspection to follow up on a warning notice for breach of regulation 17 of the Health and Social Care Act 2008 (2014 regulations). The breach stemmed from concerns identified around the systems and processes related to quality improvement and the management of patients prescribed high risk medicines.

How we carried out the 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 reviews differently.

This review was carried out remotely. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

Completing clinical searches on the practice’s patient records system and relaying the findings to the provider
Reviewing patient records to identify issues
Requesting evidence from the provider

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 undertaken some quality improvement activity in the form of one two cycle audit. The provider also submitted a single cycle audit. The two-cycle audit resulted in some changes to patient care but limited quality improvement.
There were still some areas where the provider needed to strengthen systems and processes around the management of patients prescribed medicines, including high risk medicines, and the sharing of information between other health services. The provider told us that action had been taken in respect of the issues of concern raised after our review. The provider submitted evidence after our inspection which indicated that action had been taken in response to the concerns raised.

We found that although the provider had taken action to address some of the concerns, they were still in breach of regulation 17. Therefore, the provider must:

Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care; specifically increase the amount of quality improvement activity undertaken including the number of two cycle clinical audits.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant that we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what regulatory action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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

At our previous inspection of Dulwich Medical Centre on 31 July 2019, we found breaches against Regulation 12 (Safe care and treatment), and Regulation 17 (Good governance), of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We rated the practice as Requires Improvement overall. A comprehensive follow-up inspection scheduled for 20 August 2020 was postponed due to COVID-19. However, following an internal quality assurance review, it was decided that assurance and evidence be sought from the provider remotely, on the action taken to address the Requirement Notices issued after the July 2019 inspection.

Having reviewed the assurance and evidence submitted to us by the provider, we determined that the breaches of Regulations found at the July 2019 inspection had not been adequately addressed. As a result, we undertook a focused inspection on 28 August 2020, at short notice to the provider, to confirm that they had carried out their plan to meet the legal requirements in relation to the breaches in regulations. This report only covers findings in relation to those requirements, and the practice was not rated as a consequence of this inspection. The details of our previous inspections can be found by selecting the ‘all reports’ link for Dulwich Medical Centre on our website at www.cqc.org.uk.

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.

During the inspection of 28 August 2020, we found the provider had made some improvements in providing services. Specifically:

Action had been taken to address staff shortages and was ongoing. We saw evidence of additional recruitment of clinical and administrative staff. We reviewed a selection of staff rotas and found overall clinical cover was greater than at our previous inspection in July 2019.
There was a system of recruitment checks for staff that included all information relevant to their employment roles. This included systems to verify and monitor the use of locum agency staff, and to support them in the completion of their duties.
Staff prescribing practice and prescribing data was being reviewed, managed and monitored.
Blank prescription forms were stored safely, monitored and recorded throughout the practice. The blank prescription forms were accessed from, then returned to, a secure locked store cupboard.
Staff worked flexibly across two of the provider's locations to improve service quality.
The provider had made improvements to the prescribing of high-risk medicines and auditing of patients on high-risk medicines was taking place. For example, the prescribing practice of non-medical prescribing staff and relevant data was reviewed, managed and monitored appropriately by the provider’s medicines teams.

We found there were areas where the provider had not made sufficient improvement in providing services. Specifically:

Processes for managing risks, issues and performance were not always effective. There was limited quality improvement activity to improve the quality and safety of patient care, notably with regards to clinical audits.
The practice did not always act on appropriate and accurate information. We found that clinical meetings to review patients who were prescribed high-risk medicines did not take place on a regular basis.
There were issues with monitoring arrangements for patients who were prescribed high-risk medicines.

We issued a Warning Notice in respect of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took this action because of the provider's lack of timely management to address issues previously identified, that could result in patient harm.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant that we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what regulatory action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Dr Rosie Benneyworth MB BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

This practice is rated as Requires Improvement overall. (Previous rating December 2016 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We undertook this comprehensive inspection on 31 July 2019, in response to information of concern we received.

At this inspection we found:

There were gaps in systems to assess, monitor and manage risks to patient safety; particularly in relation in the lack of salaried GPs and the lack of comprehensive induction for locum GPs.
The practice had systems for the appropriate and safe use of medicines, including medicines optimisation. However, some medicines management arrangements were not operating effectively.
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.
There was limited monitoring of the outcomes of care and treatment.
The practice did not have a comprehensive induction programme for locum GPs, and there were gaps in staff supervisions.
Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
There was a lack of regular GPs that led to reduced flexibility in the services offered, and a lack of continuity of care.
Complaints were listened and responded to.
Leadership was complex and did not always function as intended.
The practice’s processes for managing risks, issues and performance were not always effective.
The practice did not always act on appropriate and accurate information.
There was some evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements as they are in breach of regulations are:

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.

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

The areas where the provider should make improvements are:

Carry out a fire drill in line with their fire safety procedures.
Provide information about the practice performance for patients and visitors.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 11 August 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 in place for reporting and recording significant events.
Risks to patients were assessed and well managed.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
The practice had two vacant GP posts, and their analysis of GP capacity had found they were regularly failing to fill GP sessions. The practice had taken action to mitigate risks to patients by employing additional health care staff.
Patients said they were treated with compassion, dignity and respect and they 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.
Some patients said they found it difficult to book appointments. The practice had introduced a new appointment system in April 2016 and were monitoring patient feedback about the new system.
There was continuity of care for patients, with urgent appointments available the same day.
The practice had good facilities and was well equipped to treat patients and meet their needs.
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 areas where the provider should make improvements are:

Continue to monitor and take action to improve patient satisfaction with making appointments.

Review how they identify carers so they are able to offer appropriate support.

Ensure that quality improvement initiatives including audits clearly demonstrate learning and improvement.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dulwich Medical Centre on 05 November 2015. Overall the practice is rated as requires improvement.

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 in place for reporting and recording significant events.

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.

Information about how to complain was available and easy to understand.

The practice had good facilities and was well equipped to treat patients and meet their needs.

There was a clear leadership structure and staff felt supported by management.

The practice monitored outcomes for patients with long-term physical and mental health conditions. They had taken action to improve the level of care for these patients through the employment of staff with specific responsibilities. Clinical audits were used to check the progress of the improvement programme.

The provider was aware of and complied with the requirements of the Duty of Candour.

Risks to patients were assessed but not all risks had been well managed. For example, risks relating to emergency medicines and Control of Substances Hazardous to Health Regulations (COSHH; 2002) had not been adequately addressed.

The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to. The provider had not adequately responded to patient feedback.

Appointment systems were not working well and patients found it difficult to understand how to make an appointment and access services in a timely manner.

The areas where the provider must make improvements are:

Analyse and respond to feedback received from patients as part of a process of driving improvements in care and service.
Monitor and audit the appointments system in order to drive improvement in the quality of access for patients as well as communicate more effectively with patients around changes to the appointments system, including the triage process and access to emergency appointments.

Carry out a Disability Discrimination Act audit to identify whether or not all reasonable adjustments to the premises have been made for wheelchair users and those with limited mobility.

Review the emergency medicines list and associated response protocols to ensure that all relevant medicines are kept and are easily and immediately available for use in an emergency.

Carry out an assessment of substances that may potentially be hazardous to health in line with the Control of Substances Hazardous to Health Regulations (COSHH; 2002) with a view to preventing or reducing exposures to these substances.

Engage clinical staff in a formal appraisal process and ensure that all members of staff have a personal development plan in place.

The area where the provider should make improvements are:

Review the complaints process to ensure that all relevant information is recorded and that complaints are acknowledged and responded to in a timely manner.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Dulwich Medical Centre Also known as DMC Crystal Palace Road

All Inspections

13 July 2023

During an inspection looking at part of the service

Remote clinical assessment 20 September 2022 and site visit 22 September 2022

During a routine inspection

26 April 2022

During an inspection looking at part of the service

21 September 2021

During an inspection looking at part of the service

14 April 2021

During a routine inspection

28 August to 28 August 2020

During an inspection looking at part of the service

31 Juy 2019

During a routine inspection

11 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field CBE FRCP FFPH FRCGP

5 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)