The Care Quality Commission
  • Doctor
  • GP practice

Denham Medical Centre

Overall: Good read more about inspection ratings

Queen Mothers Drive, Denham Garden Village, Uxbridge, Buckinghamshire, UB9 5GA (01895) 832012

Provided and run by:
Denham Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Denham Medical Centre 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 Denham Medical Centre, you can give feedback on this service.

01 July 2022

During an inspection looking at part of the service

We carried out an announced desk-based review inspection at Denham Medical Centre in Buckinghamshire on 1 July 2022. Overall, the practice is rated as Good.

At our previous inspection in March 2020, the service was rated Good overall, however we identified concerns relating to an aspect of the provision of effective services to ‘working-age people’. The specific concerns were due to cancer screening performance and cancer-related outcomes. We therefore rated the ‘working-age people’ population group as Requires Improvement.

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

Why we carried out this inspection

In October 2021, we (Care Quality Commission) amended how we report and rate GP practices. Although the amendment saw the removal of population groups, this inspection reviewed information and followed up on the improvements the practice had made in relation to cancer screening performance and cancer related outcomes, both of which had contributed to the ‘working-age people’ population group being rated Requires Improvement. We have not changed or provided any updated ratings at this inspection.

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 with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Review of cancer outcome data
  • 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.

At this inspection, on 1 July 2022, we found the practice had addressed the issue identified at the last inspection.

We found that:

Following the March 2020 inspection, the practice reviewed cancer screening performance and cancer-related outcomes with a view to improve uptake. The review led to a variety of actions, this included:

  • The appointment of one of the GPs to become the practice ‘Cancer Champion’ – a designated lead role, to oversee how the practice managed cancer outcomes. They attended external training and meetings and shared findings with the full practice team.
  • Practice staff joined an interactive primary care network (PCN) event facilitated by a leading cancer charity.
  • Further PCN work reviewed and benchmarked cancer performance across the four other GP practices within the PCN.
  • An additional focus on early diagnosis initiatives, cancer-related clinical audits and different tools of patient engagement.
  • Engagement with the Thames Valley Cancer Alliance, specifically the early diagnosis and innovation pathway.
  • The practice provided evidence which demonstrated the actions had been successful and improvements had been made. This included improvements in cancer screening performance, cancer-related outcomes and cancer indicators.

We also saw the practice had made additional improvements in the area we asked them to consider at the last inspection, for example:

  • The practice had continued to make improvements in the delivery of the child immunisation programme, this included improvements across all age groups. For example, 98% of children aged one had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib), Hepatitis B (Hep B) ((i.e. three doses of DTaP/IPV/Hib/HepB). This was a 3% increase on the previous data collection.

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

  • Continue to improve the uptake of cervical screening.

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

3 March 2020

During a routine inspection

We carried out an announced comprehensive inspection at Denham Medical Centre in Buckinghamshire on 3 March 2020 as part of our inspection programme.

At the last inspection in April 2019, we rated the practice as Requires Improvement for providing responsive and well-led services resulting in an overall rating of Requires Improvement because:

  • Complaints were not handled in accordance with regulations. We found systems and processes for managing complaints were in place however, these were not used effectively.

  • The arrangements for governance were not operated effectively. It was unclear which governance arrangements, strategies or plans had been reviewed.

  • Staff morale and feedback was mixed.

  • There was limited engagement with patients. For example, there had not been a recent patient survey and there was no active Patient Participation Group (PPG) in place.

The full comprehensive report on the April 2019 inspection can be found by selecting the ‘all reports’ link for Denham Medical Centre on our website at .

At this inspection (March 2020), we found improvements had been made and the provider is now compliant with the regulations. We have rated this practice as Good overall and Good for all population groups with the exception of the population group: Working age people. This population group has been rated as Requires Improvement for the provision of effective services and overall, due to cancer screening performance and outcomes. This included the cancer detection rate which resulted from a two week wait referral which was significantly below the local and national average.

We found that:

  • The practice had made improvements since our last inspection in April 2019 and they were meeting regulations relating to the management of complaints and governance arrangements that had previously been breached.

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.

  • Patients’ needs were assessed, and care was planned and delivered following best practice guidance. This included significant improvements for the provision of care to patients with a learning disability.

  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.

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

  • Systems were in now place to identify and record all feedback from patients.

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

  • Improved levels of involvement and engagement with patients, the public and staff. The practice had opened communication channels with practice patients including re-launching a patient participation group (PPG) and created a PPG noticeboard within the practice.

  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice now had an effective governance system in place, was well organised and actively sought to learn from previous inspections, performance data, complaints, incidents and feedback.

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

  • Develop further methods to ensure patients received appropriate care, reviews and monitoring. This would include a review of the exception reporting processes, child immunisation programme, participation in cancer screening and the cancer referral process.

  • Continue to review access to services including opening times.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Bennyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

2 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at Denham Medical Centre in Buckinghamshire on 2 April 2018 as part of our inspection programme.

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 overall and requires improvement for all population groups.

We rated the practice as good for providing safe services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had appropriate systems in place for the safe management of medicines.

We rated the practice as good for providing effective services because:

  • With the exception of patients with learning disabilities, outcomes of care and treatment was monitored. The management of urgent test results was robust and the practice was proactive in ensuring patients received the urgent care and treatment as quickly as possible.

  • The practice could show that staff had the skills, knowledge and experience to carry out their roles.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

  • The practice organised and delivered services to meet patients’ needs including the provision of services for people with caring responsibilities.

We rated the practice as requires improvement for providing responsive services because:

  • Complaints were not handled in accordance with regulations. We found systems and processes for managing complaints were in place however, these were not used effectively.

  • Patients said they had timely access to services, the appointment system was easy to use and the information technology available supported their access to services.

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

  • The arrangements for governance were not operated effectively. It was unclear which governance arrangements, strategies or plans had been reviewed.

  • Staff morale and feedback was mixed.

  • There was limited engagement with patients. For example, there had not been a recent patient survey and there was no active Patient Participation Group (PPG) in place.

The areas where the provider must make improvements are:

  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
  • 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).

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 have not revisited Denham Medical Centre, as part of this review because it was able to demonstrate that it was meeting the standards without the need for a visit.

During a routine inspection

Letter from the Chief Inspector of General Practice

In April 2016, during our previous comprehensive inspection of Denham Medical Centre, we found issues relating to the safe and effective delivery of healthcare services. The practice also needed to review and monitor their governance arrangements. As a result of this inspection, we asked the practice to make further improvements; in order to address the high risk issues identified during their most recent fire safety risk assessment; ensure national safety and medicines alerts and National Institute for Health and Care Excellence (NICE) best practice guidelines were followed up systematically; undertake all necessary recruitment checks to carry out Disclosure and Barring Scheme (DBS) checks or risk assessments; and ensure all staff had undertaken essential training such as safeguarding children and adults.

Furthermore, the practice also needed to review and monitor the system in place to improve the outcomes for patients with learning disabilities; review patients’ feedback and address concerns identified from the national GP Patient Survey regarding the GPs and the introduction of pre-bookable online appointments.

Following the last inspection, the practice was rated as requires improvement in safe and effective services, and good for caring, responsive and well led services. The practice had an overall rating of requires improvement.

We carried out a desk based inspection in November 2016 to ensure the practice had made improvements since our last inspection. The practice sent us evidence in the form of a fire quality assurance report, a staff training log, bluestream academy (bluestream is a type of online training for healthcare providers and professionals) reports, a learning disability appointments record and evidence of a learning disability database search carried out by the practice.The practice also further supplied a chart outlining the areas the practice had changed to make improvements. We found the practice had made some improvements since our last inspection in April 2016.

At this inspection we found that:

  • The practice had taken steps to address the high risk issues identified during their previous fire risk assessment.

  • The practice had provided a copy of a quality assurance report produced by an independent company.

  • Steps were taken by the practice to address issues surrounding GP and administrative staff training in adult safeguarding and child protection.

  • The practice had provided evidence of staff training by supplying bluestream academy reports, and a copy of a staff training log.

  • Policies and procedures for Disclosure and Barring Scheme (DBS), and the recruitment of new staff were provided.

  • Steps were taken by the practice to review patient feedback.

The areas where the provider should make improvements are:

  • Continue to review and monitor the system in place, to improve the outcomes for patients with learning disabilities.

  • Ensure the governance arrangements in place for the delivery of safe and effective services are fully embedded.

Following this desk based inspection we have rated the practice as good for providing safe and effective services. The overall rating for the practice is good. This report should be read in conjunction with the full inspection report of 20 April 2016. A copy of the full inspection report can be found at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

20 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Denham Medical Centre on 20 April 2016. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for provision of safe and effective services. It was good for providing caring, responsive and well-led services. The concerns which led to these ratings apply to all population groups using the practice.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. The majority of information about safety was recorded, monitored and reviewed.
  • Risks to patients and staff were assessed and well managed in some areas, with the exception of those relating to fire safety and safeguarding children and adults training. For example, the practice did not develop written action plan with clear time scales to address the high risk issues identified during recent fire safety risk assessment carried out on 29 June 2015.
  • We found that completed clinical audits cycles were driving positive outcomes for patients.
  • 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. However, most staff had not completed health and safety, equality and diversity, fire safety and infection control training.
  • Results from the national GP patient survey showed majority of patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment when compared to the local and national averages. The majority of patients we spoke with on the day of inspection confirmed this.
  • Information about services and how to complain were available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP, 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 must make improvements are:

  • Develop written action plan with clear time scales to address the high risk issues identified during recent fire safety risk assessment.
  • Ensure all staff have undertaken training including safeguarding children and adults, health and safety, equality and diversity, fire safety and infection control.
  • Review and monitor the system in place, to improve the outcomes for patients with learning disabilities.

In addition the provider should:

  • Ensure national safety and medicines alerts and National Institute for Health and Care Excellence (NICE) best practice guidelines are followed up systematically after they are disseminated within the practice, to monitor that required changes have been implemented.
  • Ensure all necessary recruitment checks are in place including systems for assessing and monitoring risks, carrying out Disclosure and Barring Scheme (DBS) checks or risk assessment.
  • Review patients feedback and address concerns identified on the national GP patient survey regarding GPs listening, giving enough time, involving in decisions, and explaining tests and treatments during consultations.
  • Review patients feedback regarding the introduction of pre-bookable online appointments.
  • Review and monitor the governance arrangements in place to ensure the delivery of safe and effective services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice