This practice is rated as requires improvement overall. (Previous rating October 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection of this practice on 8 December 2014 when the practice was rated as requiring improvement overall (inadequate for providing responsive services; requires improvement for providing safe, effective, caring and well-led services).

We carried out another announced comprehensive inspection on 7 November 2016 when the practice continued to be rated as requiring improvement overall (requires improvement for providing safe, effective and caring, responsive and well-led services).

We carried out a further announced comprehensive inspection on 29 September and 4 October 2017, when the practice was rated as inadequate overall (inadequate for providing safe, effective and caring, responsive and well-led services). As a result, the practice was placed into special measures.

The full comprehensive reports on these previous three inspections can be found at: .

At this inspection we found:

• The practice had improved many aspects of how the service was managed and delivered. There was improved leadership capacity within the practice, and this had supported a focus on addressing previous areas of concern.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice had started to review the effectiveness and appropriateness of the care they provided. They ensured that care and treatment was delivered according to evidence- based guidelines. However, performance in some areas was lower than comparators.
• Staff involved and treated patients with compassion, kindness, dignity and respect. However, the practice had not yet demonstrated the improvements they had implemented were leading to improved patient satisfaction levels.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Follow up and maintain evidence of a full employment history for all new and existing staff.
• Develop a system to increase identification of patients who are also carers and continue to develop support for carers.
• Provide information to patients on the complaints process in a range of the most common language spoken by patients whose first language was not English.
• Develop and build upon the quality improvement arrangements to ensure the practice monitors and acts upon information about the quality of the service and clinical audits to support continued service improvements.

I am taking this practice out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We first carried out an announced comprehensive inspection of this practice on 8 December 2014. We rated the practice then as requires improvement for providing safe, effective, caring and well-led care, we rated the practice as inadequate for providing responsive care. There were breaches of regulation, in particular we found the systems and processes were not operated effectively in order to assess, monitor and improve the quality of service provided in carrying out the regulated activities. We also found that systems to assess the risk and prevent, detect and control the spread of infection and the systems to ensure the premises were maintained were ineffective. After the inspection, the provider wrote to say what they would do to address the issues raised at the inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dilston Medical Centre on our website at www.cqc.org.uk.

We undertook this comprehensive inspection on 7 November 2016 to check that the practice had followed their plan.

Overall, the practice is rated as requires improvement.

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

• The practice had complied with two of the requirement notices we set following the last inspection. We found that the practice had effective systems to assess the risk and prevent, detect and control the spread of infection and that the systems to ensure the premises were maintained were more effective. However, while the practice had demonstrated the ability to improve their governance systems, we found areas where the practice must make improvements.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, when things went wrong, reviews and investigations were not sufficiently thorough to support improvement.
• Most risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. However, it was only available in English; it was not available in other languages to suit the practice population.
• Patients said that they sometimes had to wait a long time for non-urgent appointments. Urgent appointments were usually available on the day they were required. However, the practice sometimes referred patients requiring an urgent appointment to the local walk in centre during the practice’s normal opening hours.

• The practice had good facilities and was well equipped to treat patients and meet their needs. However, the practice was aware of the need to make improvements to the building.
• There was a clear leadership structure and staff felt supported by the management structure and clinical team. The practice proactively sought feedback from staff. However, there were limited arrangements to seek feedback from patients.
• The provider was aware of and complied with the requirements of the duty of candour regulation.

The areas where the provider must make improvements are:

• Review the systems and processes in place to assess, monitor and improve the quality and safety of the service provided. Specifically, to enable lessons to be learned from significant events to prevent their reoccurrence and to improve the outcomes of patients at the practice. In addition, the practice’s quality improvement and governance systems were not effective.
• Ensure that the required staff recruitment checks are completed; specifically ensure all clinical staff have a Disclosure and Baring Service check carried out.

The areas where the provider should make improvements are:

• Complete the process for the registration of the partnership with the Care Quality Commission.
• Review arrangements for the management and distribution of blank prescription forms to take into account national guidance.
• Continue to review their arrangements to effectively capture the views of patients to improve the service provided by the practice.
• Take steps to improve the identification of carers at the practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a planned comprehensive inspection of Dilston Medical Centre on 8 December 2014.

Overall, we rated the practice as requires improvement. Specifically, we found the practice to require improvement for providing safe, effective, caring and well led services. It also required improvement for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). It was inadequate for providing a responsive service.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses
• Risks to patients were assessed but action to address concerns was not always taken in a timely manner.
• Data showed patient outcomes were broadly comparable to the national averages.
• Infection control audits had been carried out, but they were not always used to drive improvements.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was not readily available in various languages to suit the practice population.
• Urgent appointments were not always available on the day they were requested. Patients said that they sometimes had to wait a long time for non-urgent appointments.
• The practice had a number of policies and procedures to govern activity, which were being reviewed and updated. The practice held regular governance meetings.
• The premises were not being adequately maintained.
• The practice had not proactively sought feedback from patients.

The areas where the provider must make improvements are:

• Ensure there are effective mechanisms in place to identify, assess and manage risks relating to health, welfare and safety of service users.

• Ensure there are effective systems designed to assess the risk of and prevent, detect and control the spread of infection.

• Ensure that there are effective systems in place to ensure that the premises are adequately maintained.

• In addition the provider should:

• Consider implementation of arrangements to effectively capture the views of patients to improve the service provided by the practice.

• Consider implementation of arrangements to ensure adequate numbers of appointments are available to meet the needs of patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We first carried out an announced comprehensive inspection of this practice on 8 December 2014. We rated the practice then as requiring improvement for providing safe, effective, caring and well-led care. We rated the practice as inadequate for providing responsive care. We carried out a further announced comprehensive inspection on 7 November 2016. We rated the practice as requiring improvement for providing safe, effective, caring, responsive and well led care.

The full comprehensive reports on the December 2014 and November 2016 inspections can be found by selecting the ‘all reports’ link for Dilston Medical Centre on our website at www.cqc.org.uk.

We carried out this comprehensive inspection on 25 September 2016 and 4 October 2017, to check whether the provider had followed their action plan and had taken steps to comply with all legal requirements. Overall, the practice is now rated as inadequate.

Our key findings were as follows:

• There was evidence the lack of leadership and oversight in the practice resulted in ineffective systems to identify and respond to emerging and knowable safety risks.
• There was a lack of shared vision within the partnership. The practice did not have effective strategies in place to proactively make sustainable improvements.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. There were concerns about the processes for infection control, handling clinical correspondence and premises were not adequately maintained.
• When things went wrong, reviews and investigations were not always sufficiently thorough and did not always include all relevant people.
• Patients’ outcomes were very variable, and sometimes significantly worse, when compared with other similar services.
• There was a continuing trend on the National GP Patient Survey (July 2017) of well below average results.
• There was no evidence that audit was driving improvement in patient outcomes.
• Patients found it hard to access services because the facilities and premises were not appropriate for the service being provided. The practice had not considered different ways of working to maximise the use of clinical rooms.
• The practice had made improvements to the way they informed patients about the services available.

The areas where the provider must make improvements are:

• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
• Ensure all premises and equipment used by the practice is fit for use.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

• Clarify the policies and procedures for offering a chaperone service and make sure staff are familiar with this policy.
• Improve the arrangements to manage risks where capacity for appointment availability is outmatched by patient demand.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice