Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Dawes Family Practice on 26 June 2018. The overall rating for the practice was good with safe as requires improvement. The full comprehensive report for the June 2018 inspection can be found by selecting the ‘all reports’ link for The Dawes Family Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 29 October 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 26 June 2018. This report covers our findings in relation to those requirements.

The rating of requires improvement previously awarded for safe following our full comprehensive inspection in June 2018 is now improved to good.

Our key findings were as follows:

• Comprehensive risk assessments for health and safety and premises and security had been carried out.
• The practice had reviewed and updated its process and policy on the prescribing of high risk medicines.
• The practice had reviewed and updated its safeguarding policy and now included a section on female genital mutilation (FGM) and PREVENT which is about preventing terrorism.
• A practice survey was taking place throughout November and December concentrating on the questions in the national survey where patient satisfaction was low.
• A role specific induction process had been developed and implemented since the previous inspection.

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

This practice is rated as Good overall. (Previous rating February 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive at The Dawes Family Practice on 26 June 2018 as part of our inspection programme.

At this inspection we found:

• The practice had 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 routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• The practice, with other practices in the Clinical Commissioning Group and the wider NHS, had receptionists who were trained as care navigators who signposted patients to the right person at the right time across a variety of health services.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way

The areas where the provider should make improvements are:

• Update the safeguarding policy to include all up to date information
• Implement further strategy for improving patient survey results
• Develop and implement a role specific induction process

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

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Dawes family Practice Rochdale  on 17 February 2015. We spoke with patients, members of the patient participation group and staff, including the management team.

The practice was rated as good overall. A safe, caring, effective, responsive and well-led service was provided that met the needs of the population it served.

Our key findings were as follows:

• All staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• The practice was proactive in using methods to improve patient outcomes. Best practice guidelines were referenced and used routinely.
• Feedback from patients was positive. We observed a patient centred culture and found strong evidence that staff were motivated and inspired to provide kind and compassionate care.
• The practice reviewed the needs of their local population and had initiated positive service improvements for patients. .
• The leadership culture was open and transparent. The practice partners had a clear understanding and commitment to the needs of staff. We found high levels of staff satisfaction.
• Patients told us they were treated with compassion, dignity and respect and they were involved in care and treatment decisions.
• We observed staff interaction at reception to be caring, professional and supportive when working with some with challenging situations.
• The practice was clean, tidy and organised well however there had not been an infection prevention and control audit carried out at the practice in the last 12 months.

We saw several areas of outstanding practice including:

• The practice employed a dedicated carer’s advocate available during normal practice hours to assist carers with their needs.
• The waiting area of the practice contained a variety of resources to assist and signpost patients with their on going needs and information was appropriately displayed to allow easy access for patients including those patients with learning/disability needs.

In addition the provider should:

• Ensure there is an auditable system for reviewing and monitoring the recording of serial numbers on blank hand written prescriptions pads held in storage and once allocated to GPs.
• Ensure the business continuity plan is available to all staff.
• Ensure all risk assessments are appropriately recorded and available to ensure patient and staff safety.
• Ensure all staff are included in the governance processes of the practice.
• Ensure an infection prevention and control audit is carried out.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice