DMC Chadwick Road

We carried out an announced comprehensive inspection at DMC Chadwick Road on 29 September 2016. The overall rating for the practice was Good.

Following an inspection in August 2020 of a different location where services were also delivered by the provider Dulwich Medical Centre, we found breaches of regulation and risk of patient harm. We carried out an inspection at DMC Chadwick Road in December 2020 to assure ourselves the breaches of regulation and risk of patient harm were not being repeated.

At the December 2020 inspection, we found similar concerns, which resulted in breaches of regulations. We took enforcement action, and issued a Requirement Notice for a breach of Regulation 18 (Staffing) and two Warning Notices for a breach of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

We carried out an unannounced focussed follow-up inspection between 30 March 2021 and 15 April 2021 to confirm the practice had met the legal requirements in relation to the breaches of regulations identified in our inspection in December 2020. We found the practice had made some improvement and had met the requirements of the Regulation 17 Warning Notice. However, they had not sufficiently met the requirements of the Regulation 12 Warning Notice.

We carried out a further unannounced focussed inspection on 22 June 2021 to confirm the provider had met the legal requirements in relation to the continued breach of regulation identified in the April 2021 inspection.

We found further improvements had been made and risks to patients, staff and visitors were now effectively assessed, monitored and managed. However, actions required to address risks identified by the infection prevention control audit were ongoing. Given the overall improvements but with the remaining risks relating to infection control, we issued a Requirement Notice for a breach of Regulation 17.

The full history of reports and inspection findings including the comprehensive report from 2016 and the unrated focussed inspections in December 2020, April 2021, June 2021 can be found by selecting the ‘all reports’ link for DMC Chadwick Road on our website at www.cqc.org.uk.

After our inspection in June 2021 the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

Why we carried out this inspection

We carried out an announced inspection on 22 October 2021 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 in June 2021.

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 site visit
• Discussions with practice staff and three patients

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.

Our findings

This practice is now rated as Requires Improvement overall.

The key questions at this inspection are rated as:

• Are services safe? – Requires Improvement
• Are services effective? – Requires Improvement
• Are services caring? - Good
• Are services responsive? – Good
• Are services well-led? – Requires Improvement

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

• The practice’s computer system did not alert staff of all family and other household members of children that were on the risk register.
• Safeguarding training was not in accordance with national guidance.
• There was an inconsistent approach to manage medicine alerts.

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

• Patients with diabetes were not always coded appropriately or monitored in line with evidence-based guidelines.
• Patients with Chronic Kidney Damage (stages three, four or five) were not monitored in line with evidence-based guidelines.
• Child immunisations performance and uptake was below the national target and required improvement.
• There was limited evidence of quality improvement activity including clinical audits.
• All staff did not have regular appraisals.

We rated the practice as Good for providing caring services because:

• Patients we spoke to told us they were treated with compassion, dignity and respect. They described staff as being friendly, caring and helpful.
• Patient feedback collected via the GP patient survey had improved and was no comparable to local and national averages.
• We saw that staff were respectful and polite when dealing with patients and maintained confidentiality.

We rated the practice as Good for providing responsive services because:

• The practice understood the needs of the local population and delivered services to help meet patients’ needs.
• People were able to access care and treatment in a timely way and improvements had been made in relation to GP patient survey satisfaction scores.
• Complaints were listened to as well as responded to and used to improve the quality of care.

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

• Although we saw improvements had been made to infection prevention and control processes, prescribing, patient feedback and cancer screening, we found new concerns and new risks which the provider did not have oversight of.
• The provider’s processes for managing risks, issues and performance were not always effective. This included risks relating to safeguarding and long-term conditions management, issues related to safeguarding, non-effective clinical audits and a lack of appraisals.
• The practice engaged with the public, staff and external partners and was in the process of reinstating a patient participation group.

The areas where the provider must make improvements are:

• 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:

• Continue to monitor and increase childhood immunisations performance.
• Further improve patient engagement and communication processes through re-engagement with the patient participation group.

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