The Care Quality Commission
  • Doctor
  • GP practice

Danes Camp Surgery

Overall: Good read more about inspection ratings

Rowtree Road, East Hunsbury, Northampton, Northamptonshire, NN4 0NY (01604) 709426

Provided and run by:
Danes Camp Surgery

All Inspections

10 January 2024

During an inspection looking at part of the service

We carried out an announced focused assessment of the responsive key question at Danes Camp Surgery at on 10 January 2024. The rating for the responsive key question is Requires Improvement. As the other domains were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires Improvement

Well-led – Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Danes Camp Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to undertake a targeted assessment of the key question of responsive.

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 inspection

This inspection 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:

  • The practice understood the needs of its local population and tailored services to meet those needs.
  • The practice adjusted services based on patient demand to support patients to access appropriate care. However, patient satisfaction with telephone access was low. A new telephone system was due to be installed in February 2024 to further improve telephone access.
  • The practice worked effectively with local partners to improve access to services for the wider patient population.
  • During the assessment process, the provider highlighted the efforts they are making or are planning to make to improve the responsiveness of the service for their patient population. The effect of these efforts are not yet reflected in patient feedback. Patient feedback was that they could not always access care and treatment in a timely way.

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

  • Continue to monitor patient satisfaction with access and support improvements where identified, particularly telephone 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

16 June 2021

During a routine inspection

We carried out an announced follow up comprehensive inspection at Danes Camp Surgery from 09 to 16 June 2021.

Danes Camp Surgery had been inspected previously:

The overall rating from the inspection on 7 August 2019 was Requires Improvement, due to concerns in providing Safe, Responsive and Well-led services. The practice was rated Good for providing Effective and Caring services.

The full comprehensive report on the August 2019 inspection can be found by selecting the ‘all reports’ link for Danes Camp Surgery on our website at www.cqc.org.uk.

At the last inspection we identified the following areas for improvement:

  • Quality monitoring systems needed to be improved so that care and treatment was delivered safely.
  • The process for summarising patient notes needed to be improved to ensure notes were up-to-date and current.
  • The process for storing controlled drugs at the practice needed to be improved.
  • Safe management of the cold chain and effective oversight of the fridge temperatures was needed.
  • All complaints needed to be reviewed in a timely and appropriate manner.
  • Effective systems and processes needed to be established to ensure good governance in accordance with the fundamental standards of care.

We were mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what type of inspection was necessary and proportionate. This was why there was a delay in re-inspecting this service.

We carried out a follow up comprehensive inspection on 18 and 19 May 2021 to confirm that the practice had resolved the outstanding issues from the previous inspections.

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 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
  • A short 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 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.
  • 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.
  • Systems and processes had improved and now ensured good governance to identify and act on the shortfalls within the service. This included systems for summarising patient notes, cold chain management and the management of complaints.
  • All medicines (including controlled drugs were stored safely and appropriately at the practice).
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

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

  • Implement audit recommendations to demonstrate that improvements have been made when a re-audit is completed.
  • Continue to improve patient care plan reviews where targets have not been met.

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

7 August 2019

During a routine inspection

We carried out an announced comprehensive inspection at Danes Camp Surgery on 7 August 2019. The practice was last inspected on 28 October 2014 when it was rated as good. We decided to undertake an inspection of this service following our annual review of the information available to us.

Our judgement of the quality of care at this service is based 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.

From the inspection in October 2014 the practice was told they should:

  • Make all staff aware of the designated lead GP for safeguarding matters.
  • Keep a record of ‘actual’ temperatures, as well as maximum and minimum, so they can be assured that the fridges reach a safe operating temperature within the recommended range.
  • Carry out an infection control audit to be assured that their performance in this area is safe.
  • Take steps to ensure there is resilience in their capacity to operate safely in the event of multiple staff absence.
  • Remove the seal of the automated external defibrillator to ensure it is readily available during an emergency and to enable a periodic visual check to be made of it.
  • Update their business continuity plan and ensure it contains specific details to support staff to deal with an emergency or major incident.
  • Engage with NENE CCG and with NHS England to ensure that there is a clear, shared vision about how the practice’s new capacity and additional services brought about by their extensive building expansion, would meet the needs of the local health economy.

The full comprehensive report on the October 2014 inspection can be found by selecting the ‘all reports’ link for Danes Camp Surgery on our website at .

The practice is rated as requires improvement overall. The overall rating for this practice is requires improvement due to concerns in providing safe, responsive and well-led services.

We rated the practice as requires improvement for providing safe, responsive and well-led services because:

  • Controlled drugs were not being safely stored at the practice.
  • There were a number of un-summarised patient notes which had not been accurately reviewed.
  • Fridge temperatures had not been accurately recorded and the practice had failed to identify or act on this.
  • Patient access to appointments continued to need improvement.
  • Complaints had not been responded to in a timely manner.
  • A lack of effective management oversight had led to the concerns we found during our inspection.
  • There was a lack of effective oversight in relation to significant events to ensure they were all categorised and acted upon as needed.

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

  • Care and treatment was being delivered effectively with good patient outcomes and a focus on learning and developing the practice.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider must make improvements are:

  • Improve the quality monitoring systems to ensure that care and treatment is delivered safely.
  • Review the process for summarising patient notes to ensure these are up-to-date and current.
  • Review the process for storing controlled drugs at the practice.
  • Ensure the safe management of the cold chain and have effective oversight of the fridge temperatures.
  • Review all complaints in a timely and appropriate manner.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

28 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected Danes Camp Surgery on 28 October 2014, as part of our new, comprehensive inspection programme. The practice had not previously been inspected.

The overall rating for this practice is good. We found the practice to be, safe, effective, caring, responsive to people’s needs and well-led. There were some areas of practice that require improvement to ensure it was operating safely. The quality of care experienced by older people, by people with long-term conditions and by families, children and young people was good. Working age people, those in vulnerable circumstances and people experiencing poor mental health also received good quality care.

Our key findings were as follows:

  • The practice was a friendly, caring and responsive practice that addressed patients’ needs and that worked in partnership with other health and social care services to deliver individualised care.
  • The clinical and administrative team had a good understanding of the needs of their patient population, particularly in relation to patients who were at most risk of poor health whose care was managed through personalised care plans.
  • The practice assured the quality of their performance by carrying out a range of clinical audits.
  • Staff were properly trained for their roles.
  • The practice performed well according to nationally collected data about its performance with the exception of patients’ experience of the availability of appointments.
  • Although patients reported poor availability of appointments, the consultation sessions ran to time and there were often un-booked appointments available at the end of the sessions.
  • Patients were treated with respect, dignity and kindness.
  • The practice enabled people with long term conditions to book appointments at times of their choosing as opposed to solely during routine clinics.
  • The practice had invested heavily in an extensive refurbishment programme that would increase the premises’ capacity and enable the practice to increase its list and provide additional services.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Make all staff aware of the designated lead GP for safeguarding matters.
  • Keep a record of ‘actual’ temperatures, as well as maximum and minimum, so they can be assured that the fridges reach a safe operating temperature within the recommended range.
  • Carry out an infection control audit to be assured that their performance in this area is safe.
  • Take steps to ensure there is resilience in their capacity to operate safely in the event of multiple staff absence.
  • Remove the seal of the automated external defibrillator to ensure it is readily available during an emergency and to enable a periodic visual check to be made of it.
  • Update their business continuity plan and ensure it contains specific details to support staff to deal with an emergency or major incident.
  • Engage with NENE CCG and with NHS England to ensure that there is a clear, shared vision about how the practice’s new capacity and additional services brought about by their extensive building expansion, would meet the needs of the local health economy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice