The Care Quality Commission
  • Doctor
  • GP practice

Southdene Medical Centre

Overall: Requires improvement read more about inspection ratings

Front Street, Shotton Colliery, Durham, County Durham, DH6 2LT (0191) 526 5818

Provided and run by:
Southdene Medical Centre

All Inspections

27 June & 3 August 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Southdene Medical Centre on 27 June and 3 August 2022. Due to some concerns we then changed the inspection to a comprehensive inspection. Overall, the practice is rated as Requires improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires improvement

At our previous inspection of 24 November 2016, the practice was rated outstanding overall and for the key questions of safe, effective and well-led. They were rated as good for the key questions of caring and effective.

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

Why we carried out this inspection

We carried out this inspection as part of our direct monitoring intelligence system Band 1 sampling exercise. This exercise is looking at a percentage of band 1 locations in each sector with published statements on our website as part of our quality assurance process to monitor the effectiveness of our new monitoring approach. We need assurance that Good or Outstanding rated locations are still good or outstanding and that we were right to publish the public statement.

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 questionnaires, phone calls and 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 Requires improvement overall

We found that:

  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses.
  • Patients mostly received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The shortage of established GPs had an impact on the practice not being able to keep up to date with care plans, medication reviews and the reviewing of prescribing.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients. (See Requirement Notice Section at the end of this report for further detail).

The areas where the provider should make improvements are:

  • Implement a system to review historical patient safety alerts.
  • Continue to review care plans for patients with poor mental health.

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

24 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Southdene Medical Centre on 24 November 2016. Overall the practice is rated as outstanding.

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

Patients were protected by a strong comprehensive safety system and there was a focus on openness, transparency and learning when things went wrong. The practice had a strong system in place for recording, monitoring and learning from significant events, accidents, complaints and reporting.

  • The practice used innovative and proactive methods to improve patient outcomes. The practice had a high rate of clinical audit for their size.

  • Outcomes for patients who use similar services were consistently better than expected when compared with similar services. Data showed that the practice was performing highly when compared to practices nationally and in the Clinical Commissioning Group. The latest publically available data from 2015/16 showed the practice had achieved the maximum points available to them for 2015/16 (100%), with a clinical exception rate of 8.2%. This was above the England average of 95.3%, and their clinical exception rate was below the England average of 9.8%.

  • The practice used creative approaches to care and treatment and placed a strong emphasis on patient education. Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice reviewed the needs of their local population and engaged with the NHS England Area Team and clinical commissioning group (CCG) to meet the needs of the individual patients to ensure flexibility, choice and continuity of care.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.
  • Patients could access appointments and services in a way that suited them. They said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. The practice had a clear vision which had quality and safety as its top priority.

  • There was a clear leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.

  • Staff throughout the practice worked well together as a team.

We two areas of outstanding practice which were:

  • The practice had all-encompassing systems and processes in place to ensure that patients received high quality care and treatment. These included learning from significant events, triggering clinical audits and then changes in clinical practice which improved patient care. For example, One of the GP partners kept a folder of NICE guidance updates which they reviewed at clinical meetings to ensure they were followed and actioned. They took action as appropriate with regards to existing patients and updated templates and guidelines and protocols the practice had in place. The practice had structured tiered templates on the practice intranet system to obtain information on medical conditions to improve patient care.
  • The practice placed a strong emphasis on patient education. In addition to the usual education provided to patients during regular appointments they arranged an education programme with diabetic patients with a local renal consultant in May 2016. The practice monitored the personal diabetes control of the patients who attended this session and found that 38% of patients who attended (eight) lost weight and improved the control of their diabetes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice