The Care Quality Commission
  • Doctor
  • GP practice

Donneybrook Medical Centre

Overall: Good read more about inspection ratings

Clarendon Street, Hyde, Cheshire, SK14 2AH (0161) 368 3838

Provided and run by:
Donneybrook Medical Centre

All Inspections

23 January 2024

During an inspection looking at part of the service

We carried out a targeted assessment of Donneybrook Medical Centre in relation to the responsive key question. This assessment was carried out on 23 January 2024 without a site visit. Overall, the practice is rated as Good. We rated the key question of responsive as Requires improvement.

Safe – good (carried over from the previous inspection)

Effective - good (carried over from the previous inspection)

Caring - good (carried over from the previous inspection)

Responsive – Requires Improvement

Well-led - good (carried over from the previous inspection)

Following our previous inspection in January 2023, the practice was rated good overall and for all key questions. At this inspection, we rated the practice as requires improvement for providing responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Donneybrook Medical Centre our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection as part of our GP-responsive assessment programme.

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the assessment

This assessment was carried out remotely.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider.

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 found that:

  • Trend data within the national GP patient survey had declined and although the practice in-house surveys were showing some improvement over a 6 month period, the improvements remained ongoing.
  • The provider hosted digital system training to support patients in using the online service provision.
  • The provider had trained staff in recognising changes to health conditions to access the correct clinician without delays.
  • Longer appointment times were made available for more complex patients to avoid multiple appointments.
  • Learning disability patients had appointments offered at times to suit their needs and home visits supported for patients who struggled to attend the practice.
  • The provider would involve all staff with complaints to gain feedback and opportunities to learn.

Whilst we found no breaches of regulations, the provider should:

  • Continue to audit patient survey data and continue to implement, review and improve patient access.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

07 December 2022

During a routine inspection

We carried out an announced inspection at Donneybrook Medical Centre on 7 December2022. Overall, the practice is rated as good.

The key questions are rated as:

Safe – Good

Effective – Good

Caring – Good (rating awarded at the last inspection February 2019)

Responsive – Good (rating awarded at the last inspection February 2019)

Well-led – Good

The provider was last inspected February 2016 and was rated Good overall and in all the key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Grosvenor Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as there were some concerns raseid in the safe domain relating to the management of medicines. We only inspected safe, effective and well-led as part of this inspection.

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 by telephone and 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
  • Gaining feedback from staff using staff questionnaires
  • A shorter 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 good overall

We have rated this practice as good for providing safe, effective and well-led services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Embedded the new templates to ensure medication reviews are fully documented.
  • Continue to regularly audit patients prescribed high risk medicines to ensure they are being monitored in a timely manner and in line with guidance.
  • Continue to work with patients to encourage the uptake of cervical screening.
  • Embedded the management oversight of the workflow system.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

20 Feb 2019

During a routine inspection

We carried out an announced comprehensive inspection at Donneybrook Medical Centre on 20 February 2019 as part of our inspection programme.

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 good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • 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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Monitor patient experience of confidentiality at reception.
  • Look to carry out annual minor surgery audits.
  • Ensure work is carried out to replace window blinds which do not meet current safety standards.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

07/1/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Donneybrook Medical Centre on 7 January 2016. Overall the practice is rated as good.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, including those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Data showed some patient outcomes were low compared to the locality and nationally. The practice was aware of the data and with a fully establish clinical team were improving outcomes in year.

  • Feedback from patients about their care was positive.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.

  • Information about services and how to complain was available and easy to understand.

  • Patients said they found it difficult to get through on the telephone and were not always able to make an appointment when they needed to. As a result of feedback the practice introduced a new telephone system.

  • All patients had a named GP and there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider should make improvement are:

  • Ensure appointments and the telephone system are monitored to improve access.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

20 May 2014

During a routine inspection

Donneybrook Medical Centre operates a weekday service for patients in the Hyde, GeeCross, Newton, Dukinfield, Denton, Godley and Hattersley area.   Donneybrook Medical Centre provides an extended service so opens at 7.00am one day a week and closes at 6.00pm five days a week.  The surgery is responsible for providing primary care, which includes travel vaccinations, family planning, well woman and well man clinics, cervical smears, smoking cessation and asthma clinics.  The practice is registered with the Care Quality Commission to deliver the following regulated activities:

  • diagnostic and screening procedures
  • family planning
  • maternity and midwifery services
  • surgical procedures
  • treatment of disease, disorder or injury. 

The patients we spoke with and who completed our comment cards were very complimentary about the care provided by clinical and non-clinical staff.  They said they are always treated with respect and the GPs are attentive and patient.  They said that overall, the reception staff are friendly and helpful.  Patients told us they have enough time during their consultation to talk about their health issues and their GP is attentive to their care needs.  Patients confirmed they are involved in making decisions about their care and their GP explains everything about their treatments in a way they can understand.

The practice has good systems in place to safeguard patients from the possible risk of abuse and harm. 

Staff spoken with said they enjoy their work and feel well supported in their role.

Improvements are needed to the records kept about complaint investigations, staff personnel files and the way medicines are checked and stored.