We carried out an announced comprehensive inspection at Denton Village Surgery on 2 April 2019.

This was the first inspection at the practice under their current registration with CQC.

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 and good for all the population groups.

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

• The practice did not have clear systems and processes to keep patients safe.
• The practice did not have all of the required emergency drugs in stock to ensure patient safety.
• The practice did not have an adequate system in place to safely manage MHRA and other safety alerts.
• Staff immunisations were not being safely monitored.
• The practice had over 500 patient notes which had not been summarised dating back to 1984. This had not been picked up by the practice prior to our inspection and posed a risk to patient safety.
• Some of the risk assessments in place in the dispensary did not provide enough information to safely mitigate any identified risks.

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

• Patients received effective care and treatment.
• Screening and immunisation data for the practice was good.
• 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.

We rated the practice as inadequate for providing well-led services because:

• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• The overall governance arrangements were ineffective due to areas of risk which had not been identified prior to our inspection.
• The practice did not have clear and effective processes for managing risks.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Ensure blind chords in the waiting room are safe and do not pose any risks to patients.
• Review staff training needs and ensure staff have the skills, knowledge and experience to carry out their roles.

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