The Care Quality Commission
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  • GP practice

Archived: Daneshouse Medical Centre

Overall: Inadequate read more about inspection ratings

Old Hall Street, Burnley, Lancashire, BB10 1BH (01282) 423288

Provided and run by:
Dr Kazam Ali Khan

Important: The provider of this service changed - see old profile

All Inspections

27 June to 27 June 2018

During a routine inspection

This practice is rated as inadequate overall. (Previous rating December 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Inadequate

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Daneshouse Medical Centre on 27 June 2018 to follow up breaches to regulations identified at our previous inspection in December 2017.

At this inspection we found:

  • The provider had failed to respond appropriately to the concerns identified at the previous inspection and we identified a number of areas where the practice had deteriorated since our last visit.
  • The improvements previously made to systems around managing risk, so that safety incidents were less likely to happen had not been consistently maintained. We saw when some incidents had occurred, the practice learned from them and improved its processes, however, other incidents had not been acknowledged or documented by the provider.
  • We found evidence the practice was not consistently delivering care and treatment in line with evidence based guidelines. We saw examples where patients’ medication was not being appropriately monitored through reviews and health checks as necessary.
  • Clinical leaders lacked comprehensive managerial oversight of the challenges the practice was facing, with limited insight demonstrated as to how they would be addressed moving forward.
  • While patient outcomes for hypertension had improved since out previous visit, outcomes for patients with diabetes had either deteriorated or remained below local and national averages.
  • Clinical audit demonstrated limited evidence of quality improvement.
  • Patient feedback regarding the standard of care and treatment received and access to appointments was lower than local and national averages.
  • Staff did not feel supported or valued and we observed strained working relationships. The practice was experiencing difficulties recruiting and retaining staff.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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.

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

1 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection April 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We undertook a comprehensive inspection of Daneshouse Medical Centre on 5 April 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as inadequate, and we issued warning notices for breaches identified to Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Receiving and acting on complaints) and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). The practice was placed into special measures following this visit. The full comprehensive report following the inspection in April 2017 can be found on our website here: http://www.cqc.org.uk/location/1-586401697.

We then undertook a follow up focused inspection of Daneshouse Medical Centre on 22 August 2017. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice had addressed concerns identified in the warning notices issued.

We undertook a further announced comprehensive inspection of Daneshouse Medical Centre on 1 December 2017. This inspection was carried out following the period of special measures to ensure further improvements had been made and to assess whether the practice could come out of special measures.

Our key findings were as follows:

  • The practice had improved its systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice documented investigations resulting from them and improved their processes.

  • Clinicians were aware of evidence- based guidelines.

  • Audits had been undertaken, however these were single cycle and changes made as a result had not yet been monitored for effectiveness.

  • The practice had improved its performance against the national Quality and Outcomes Framework (QOF) compared to the previous year (QOF is a system intended to improve the quality of general practice and reward good practice).

  • Improvements had been made to how complaints were managed and handled, although we did find an example where the practice’s response had not adhered to its own complaints policy.

  • Managerial oversight of staff training had improved, and there was a more systematic approach to staff appraisals. However, there were gaps in documentation relating to some clinical role-specific training.

  • Practice policy and procedure documents had been updated to make them practice specific, although we were not fully assured they were all sufficiently embedded to ensure they were adequately followed.

  • Patients continued to find the appointment system challenging and some reported that they were not always able to access care when they needed it.

  • Patients we spoke with were positive about their interactions with staff and said they were treated with compassion and dignity. However, results from the national GP patient survey continued to show patients rated the practice lower than others for many aspects of care.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

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

In addition the provider should:

  • Document a formal risk assessment for emergency medicines held on site.

  • Document an action plan following completion of infection prevention and control audits to facilitate improvements being made in a timely manner.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Daneshouse Medical Centre on 5 April 2017. The overall rating for the practice was inadequate, and we issued warning notices for breaches of Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Receiving and acting on complaints) and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). The full comprehensive report following the inspection in April 2017 can be found on our website here: http://www.cqc.org.uk/location/1-586401697.

This inspection was an announced focused inspection carried out on 22 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches identified within the warning notices.

Our key findings were as follows:

  • The practice had made improvements to its procedures for handling complaints and was found to be meeting Regulation 16 (Receiving and acting on complaints).

  • While some progress within the practice’s governance arrangements had been made, we found that further improvements were required.

  • The system for identifying, recording, and investigating significant events had improved.

  • Some improvements had been made around managing risk.

  • Information contained in practice policy and procedure documents remained inconsistent, with updated documents not yet fully embedded into practice.

  • Full ownership of designated lead roles had not been assumed. For example, the infection prevention and control lead was not aware of the content of the most recently completed IPC audit, and action had not been taken to address issues the audit had identified.

At our previous inspection on 5 April 2017, we rated the practice as inadequate and placed the service into special measures. As per our published inspection methodology, a further full comprehensive inspection visit will be carried out shortly in order to monitor the work the practice has begun to implement the required improvements to the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice