The Care Quality Commission
  • Doctor
  • GP practice

Dunsville Medical Centre

Overall: Good read more about inspection ratings

126-128 High Street, Dunsville, Doncaster, South Yorkshire, DN7 4BY (01302) 890108

Provided and run by:
Dr Chhitij Mohan

Important: The provider of this service changed - see old profile

All Inspections

During an assessment under our new approach

Date of Assessment: 20 August 2026

Dunsville Medical Centre is a GP practice in Dunsville, on the outskirts of Doncaster. It delivers services to approximately 6984 people under a contract held with NHS England and is registered with the CQC to provide treatment of disease, disorder, and injury; family planning; surgical procedures; diagnostic and screening procedures; and maternity and midwifery services.

According to the latest available data, the ethnic make-up of the service area is approximately 95.5% White, 2.1% Asian, 1.2% Mixed, 0.7% Black and 0.5% Other.

Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE

Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They generally assessed and managed the risk of infection well and took steps to control the risk of it spreading. Training which the service deemed mandatory was not up to date however and, while a review of recent recruitment showed that the service was currently following safe recruitment procedures when employing staff, some issues were identified with previous recruitment.

EFFECTIVE

Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.

CARING

Staff treated people with kindness, empathy, and compassion, and respected their privacy and dignity.

RESPONSIVE

People could access care, treatment, and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.

WELL-LED

The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. The service did not always have well-established, good governance processes in place however for some quality statements that we reviewed during this assessment and, while improvements had been made by a new practice manager, oversight required strengthening in some areas.

3 March 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Dunsville Medical Centre on 16 April 2019 and the practice was rated as good overall and requires improvement for providing safe services because:

  • The practice did not consistently have clear systems and processes to assess and mitigate risks to keep patients safe.

At this inspection we followed up on the breach of regulation identified at the previous inspection in April 2019.

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 rated the practice as good for providing safe services because:

  • The practice had reviewed systems and processes to assess, monitor and manage risks to patient safety.

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

  • Continue with plans to improve the system for regularly checking the registration of clinical staff.

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

16 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at Dunsville Medical Centre on 16 April 2019 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 good overall and good for older people, people with long term, conditions, families, children and young people and people experiencing poor mental health population groups. We rated this practice as outstanding for people whose circumstances may make them vulnerable. 

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

  • The practice did not consistently have clear systems and processes to assess and mitigate risks to keep patients safe.

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

  • Patients 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We saw areas of outstanding practice including:

  • Staff, teams and services were committed to working collaboratively and have found innovative and efficient ways to deliver more joined-up care to patients. In March 2017 the practice and six neighbouring practices developed the proactive primary coordinated care pathway. The practices hosted the pro-active care team, which included three pro-active care nurses, who visited frail, vulnerable or older patients in their own homes and implemented an advanced care plan with the patient/family/carers.  Initially, patients were assessed using a risk stratification tool  The pro-active care nurse had identified 130 patients at risk and have care plans in place. Of that 38 patients had consented to an enriched summary care record.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients (Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review and improve systems to record and report safety concerns, incidents and near misses.

  • Develop a programme or schedule of clinical audit activity which will lead to improvements to patient care and outcome.

  • Review and improve systems to record all complaints

  • Review and improve systems to monitor patients prescribed high risk medicines.

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