Dulwich Medical Centre Also known as DMC Crystal Palace Road

Updated 19 September 2023

Dulwich Medical Centre is located at 163-169 Crystal Palace Road, East Dulwich, London, SE22 9EP

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, surgical procedures and family planning.

The practice is situated within the South East London ICS and delivers General Medical Services (GMS) to a patient population of about 7,310. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices: South Southwark Primary Care Network.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the seventh lowest decile (7 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 68.5% White, 17.8% Black, 6.3% Mixed, 5.7% Asian and 1.8% Other.

There are fewer older people and more younger people registered at the practice compared with local and national averages.

There is a team of 5 GPs and 5 nurses at the practice. The GPs are supported at the practice by a team of reception and administration staff. The practice manager and operations manager provide managerial oversight.

Updated 19 September 2023

We carried out an announced comprehensive inspection at Dulwich Medical Centre on 13 July 2023. Overall, the practice is rated as Requires Improvement.

Safe - good.

Effective - requires improvement.

Caring – good.

Responsive – good.

Well-led - requires improvement.

Following our previous inspection on 22 September 2022, the practice was rated Requires Improvement overall and for providing safe, effective, caring and well-led services. The practice was rated Inadequate for providing responsive services. As a result of this inspection, the practice was placed into special measures.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from our previous inspection.

This was a comprehensive inspection to review the following domains:

• Safe
• Effective
• Caring
• Responsive
• Well-led

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 Requires Improvement.

We have rated the practice as Requires Improvement for providing effective services because:

• Improvements were needed to the uptake of childhood immunisations and cervical cancer screening.
• The practice could not demonstrate there was an induction programme for all new staff.

We have rated the practice as Requires Improvement for providing well-led services because:

• There were not always clear and effective processes for managing risks, issues and performance. In particular, the practice had not identified and managed all risks relating to; staff immunisations; uptake of childhood immunisations; uptake of cervical cancer screening; patients prescribed rescue steroids; and the induction process for all new staff

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There were clear systems in place to manage risks associated with; infection prevention and control; patient safety alerts; and significant events.
• Staff had completed required training appropriate to their role.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Improvements were seen in the National GP patient survey scores and there was evidence the practice had acted in response to this feedback.
• The practice had taken action to ensure patients could access care and treatment in a timely way.

We found one breach of regulation. The provider must:

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

The areas where the provider should make improvements are:

• Take action so that; patients prescribed ACE inhibitors or Angiotensin II receptor blockers; and patients with hypothyroidism, receive monitoring in line with best practice guidance.
• Complete and record an induction for each member of staff.

This service was placed in special measures following our inspection on 22 September 2022. The practice has made significant improvements and is now rated requires improvement overall and for providing effective and well-led services. The practice is rated good for providing safe, caring and responsive services. I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service. The service will be kept under review and will be inspected within 12 months to ensure improvements are sustained.

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