Danebridge Medical Practice

We carried out an announced inspection at Danebridge Medical Practice on 12 and 18 May 2021. Overall, the practice is rated as Good.

The ratings for each key question: -

Safe - Requires improvement

Effective - Good

Well-led - Good

Following our previous inspection on 19 February 2019, the practice was rated Requires Improvement overall. It was rated Requires Improvement for providing Safe and Well-led services and Good for providing Effective, Caring and Responsive services.

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

Why we carried out this inspection

This inspection was a focused follow-up review of information which included a site visit to follow up on:

• Breaches of regulations and ‘shoulds’ identified in the previous inspection
• Ratings for Responsive and Caring were carried forward from the previous 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:

• Conducting staff interviews using video conferencing
• Conducting an interview of Patient Participation Group members 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 site visit which included a review of records and discussion with staff

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 Good overall and Requires improvement for the safe key question and population group People with long-term conditions.

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

• Improvements were needed to the management of medication to ensure patient safety.
• Improvements were needed to the system for identifying patients with long-term conditions to ensure they received appropriate monitoring of their health needs.

We rated the practice as Requires Improvement for People with long-term conditions because:

• Improvements were needed to the system for identifying patients with long-term conditions to ensure they received appropriate monitoring of their health needs.

We found that:

• The provider had taken action to improve the service provided following the last inspection.
• There were clear systems in place for managing complaints and significant events and ensuring learning was communicated.
• The recruitment processes had been improved and the practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• The provider had put in place a system to identify issues that needed to be reported to CQC.
• There was an effective system for monitoring the training needs of clinicians and all staff and ensuring any training gaps were addressed.
• The provider had reviewed the system for monitoring blood results to ensure these were reviewed in a timely manner.
• Improvements had been made to the management of some medications, such as high-risk drugs.
• The provider had an improved programme of quality improvement and used information about care and treatment to make improvements.
• The provider had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. This included regular communication with staff to ensure they knew about changes and felt supported.
• Improvements had been made to monitor the systems to refer patients with suspected cancer to hospital, to ensure prescriptions were managed securely and monitor medication taken on home visits.
• Improvements had been made to infection control practices.
• The provider encouraged a culture to provide good quality care to patients.
• Staff felt well supported and were clear about their roles and responsibilities.
• Improvements had been made to ensure there was better communication with staff. Daily briefings were held which were then communicated to all staff by email.

We found breaches of regulations. The provider must:

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

We also found the provider should:

• Record a risk assessment to determine the range of emergency medicines held at the practices.
• Record the monitoring undertaken of the prescribing competence of non-medical prescribers.
• Clarify the protocol for managing blood results to indicate which staff are responsible for actions.
• Establish a system to check Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions document all the required information.
• Put in place a procedure for the safe use of oxygen to support the risk assessment.
• Keep the legionella risk assessments under review to address the actions indicated.
• Ensure that a record is made of in-house checks of the fire safety systems.

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