The Care Quality Commission
  • Doctor
  • GP practice

Danbury Medical Centre

Overall: Good read more about inspection ratings

52 Maldon Road, Danbury, Chelmsford, Essex, CM3 4QL (01245) 221777

Provided and run by:
The Beacon Health Group

All Inspections

During an assessment under our new approach

Date of assessment: 30 May to 17 July 2024. We conducted this assessment due to receiving information of concern. We assessed 11 quality statements across the safe, effective, responsive and well-led key questions and have combined the scores for these areas with scores from the last inspection.

The assessment included 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, speaking with staff and visiting the main location

At this assessment we found that leaders had implemented new systems, practices, and processes to help keep people safe but these were in their infancy. The practice had a system for appropriate and safe use of medicines and was developing this to demonstrate it was effective. Prior to the assessment the practice had not identified all outstanding patient medicine reviews which were apparent in the CQC clinical searches. Once identified the practice took action to respond to these and embed new systems.

The practice had not consistently learned from significant events and was taking action to sustain and embed improvements in this area. Referral processes were not consistently effective but action was being taken to mitigate this risk through the introduction of a specific team to review tasks and referrals.

Managers investigated concerns appropriately but learning was not always shared to make and embed improvement. Action had been taken to address this.

Patients did not always find it easy to access the practice by telephone however, the practice had introduced new systems and processes to address this and were monitoring these to measure improvements.

The leaders had recently changed the governance at the practice and introduced monthly patient safety meetings.

30/10/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating September 2017 – Requires Improvement).

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Danbury Medical Centre on 30 October 2018 and followed up on breaches of regulations found during the previous inspection.

At this inspection we found:

  • There was a clear leadership structure and staff felt supported by management. The practice ensured that communication across the practice sites was clear and defined.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • There were clear systems to manage risk so that safety incidents were less likely to happen.
  • When incidents did happen, the practice learned from them and improved their processes. Incidents were routinely reviewed and analysed to ensure occurrences were not repeated.
  • The practice audited and reviewed the effectiveness and appropriateness of the care it provided. Audits showed this was to ensure care and treatment was provided according to evidence-based guidelines.
  • The Danbury location dispensed medicines to patients. The arrangements for managing medicines, including emergency medicines and vaccines kept patients safe.
  • We reviewed recruitment procedures undertaken prior to employment and found staff files viewed were complete and accurate.
  • Information about services and how to complain was available. Improvements were made to the quality of care from the systems in place to learn from the lessons gained from concerns and complaints. These were shared with staff and stakeholders.
  • We observed the two locations we inspected to be tidy and generally clean.
  • Patients we spoke with said they did not always find it easy to make an appointment with a named GP however, there was continuity of care, and urgent appointments were available the same day.
  • Patient satisfaction in the national GP patient survey was low in several areas. The practice carried out their own survey using questions from the national survey to understand whether changes being made were having a positive effect.
  • We were told staff treated patients with compassion, kindness, dignity and respect.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Increase existing efforts to identify patients that are carers to ensure they are provided the support needed to maintain their health and caring role.
  • Continue to monitor patients with diabetes and hypertension to ensure that appropriate reviews are undertaken and performance in this area is maintained.
  • Continue to monitor and improve patient satisfaction as identified in the national GP patient survey published in August 2018.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

26 September 2017

During a routine inspection

We carried out an announced comprehensive inspection at Danbury Medical Centre and its branch Mountbatten House Surgery on 26 September 2017. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was a clear leadership structure and staff felt supported by management. The practice ensured that communication across both sites was clear and defined.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. However, the practice did not actively monitor trends in significant events.
  • All electrical and clinical equipment was checked and calibrated to ensure it was safe to use and was in good working order. We found some clinical consumable items had passed their expiry date for use. The practice acted on this immediately and removed them.
  • The practice dispensed medicines to patients. The arrangements for managing medicines, including emergency medicines and vaccines, in the practice kept patients safe.
  • We observed the premises to be tidy and generally clean but noted that there was staining throughout the carpets in the Mountbatten site and on the floor of a storage area at the Danbury site.
  • Staff had received training on safeguarding children and vulnerable adults relevant to their role.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • We reviewed recruitment procedures undertaken prior to employment and we found that that for two members of staff evidence of satisfactory conduct in previous employments in the form of references was missing but the remainder of staff files we viewed were complete and accurate.
  • Results from the national GP patient survey showed patients did not always rate the service highly in comparison with local and national averages. The practice was proactive in attempting to address patient concerns as raised through the survey and had implemented various changes as a result.
  • The practice had identified less than 1% of the practice population as carers but did signpost them to relevant services.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. But there was no system in place for lessons learnt from individual concerns and complaints to be shared with other staff or stakeholders.
  • Patients we spoke with said they did not always find it easy to make an appointment with a named GP but that there was continuity of care, with urgent appointments available the same day.
  • The provider was aware of the requirements of the duty of candour.

The areas where the provider must make improvement is:

  • Ensure care and treatment is provided in a safe way to patients.

There were several areas where the provider should make improvements:

  • Monitor trends in significant events and share learning from complaints and their outcomes.
  • Review the recording and coding of medical records to ensure accurate and reflective care and treatment of patients, including patients who are carers.
  • Respond appropriately to below average patient satisfaction scores in the national GP Patient Survey.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice