Dunstan Village Group Practice Also known as Earle Road Medical Centre

We carried out an announced inspection at Dunstan Village Group Practice on 11, 18 and 27 May 2022. Overall, the practice is rated as requires improvement.

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires improvement

Why we carried out this inspection

This inspection was a comprehensive inspection and the first inspection since registration with CQC.

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
• 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
• Circulating a staff questionnaire
• 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 rated the provider as inadequate for providing safe services. This is because:

• We found concerns in relation to medicines management. Appropriate monitoring was not always carried out and structured medication reviews did not contain relevant information.
• Safeguarding training had not been completed at the appropriate level, in line with intercollegiate guidance.
• The system for reviewing Patient Group Directions was not effective.
• The system for reviewing and acting on safety alerts was not effective.

However:

• Appropriate standards of cleanliness and hygiene were met.
• Recruitment and induction systems were in place.

We rated the provider as requires improvement for providing effective services because:

• We found concerns with the management of some patients with long term conditions. For example, asthma, hypothyroidism, chronic kidney disease and diabetes.
• The practice’s uptake for cervical screening was low.

We rated the provider as good for providing caring services because:

• The provider received positive feedback from patients and patients felt staff were caring and supportive.

We rated the provider as good for providing responsive services because:

• The provider had responded to patient feedback and made improvements to the service. For example, a new telephone system had been installed.

We rated the provider requires improvement for providing well-led services because:

• We found that processes and systems to support good governance were not effective.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Review and update the practice website information.
• Review sample storage arrangements.
• Review the incident process to include consideration of duty of candour.
• Continue to monitor and improve the uptake of cervical screening programme.

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