Dove River Practice

We carried out an announced comprehensive at Dove River Practice on 23 August 2022. Overall, the practice is rated as good.

Safe - requires improvement

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 12 January 2016 under a previous provider, the practice was rated good overall and for all key questions. Dove River Practice inherited this rating under its new owners.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter 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 the practice as good overall

We found that:

• The practice had not always provided care in a way that kept patients safe and protected them from avoidable harm because the systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others who may be at risk were not always effective.
• 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.
• 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. However, some areas of the practice were not managed consistently as concerns in relation to risk management identified during the inspection had not been identified or resolved by the practice.

We rated the provider as requires improvement for providing safe care and treatment. This was because:

• The registered persons had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. For example, Safety alerts were not always acted upon.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way for service users

In addition, the provider should:

• Implement Disclosure and Barring Service checks before employees commence employment.
• Update the safeguarding policies to contain all the categories of abuse. Include escalation information in complaint responses.
• Continue to address issues around infection prevention and control.
• Add alerts for parents/guardians of vulnerable children.
• Continue to complete the improvement works planned in the fire and Legionella risk assessments.

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