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Danebridge Medical Practice Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 22 May 2019

We rated the practice as good for providing caring, effective and responsive services because:

  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • 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. Patients could access care and treatment in a timely way.

We rated the population groups as good.

The area where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure specified information is available regarding each person employed or appointed.
  • Ensure specified information is referred to CQC in accordance with the (Registration) Regulations 2009.

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

The areas where the provider should make improvements are:

  • Introduce a system to monitor two-week rule referrals to ensure patients receive the clinical care they are referred for.
  • Review the security of NHS prescriptions in the practice and ensure there are systems in place to track and monitor their use.
  • Make a record of the stock levels and expiry dates of emergency medicines contained within GP bags.
  • Introduce a system for the regular cleaning of carpeted areas at Sandiway.
  • Introduce a system to check infection control standards are being maintained in between annual audits, to record spot checks of the cleaning undertaken by the cleaners and to record when equipment such as nebulisers are cleaned.
  • Introduce a system to audit patient consent to check this is being appropriately sought and recorded.
  • Introduce a comprehensive programme of quality improvement and use this information about care and treatment to make improvements.
  • The remit for referrals to the self-employed counsellors to be documented.
  • The written agreement between the counsellor, practice and patient to clearly identify what information is to be recorded, where it is to be stored and who has access to this information.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas


Requires improvement








Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable