Background to this inspection
Updated
6 June 2022
Honeysuckle Lodge is located at Tickhill Road Site, Off Weston Road, Balby, Doncaster, DN4 8QN.
The provider is registered with CQC to deliver the Regulated Activities of diagnostic and screening procedures; maternity and midwifery services; and treatment of disease, disorder or injury.
The provider is a federation of 37 GP practices located across Doncaster and provides several NHS services to the local population on behalf of its member practices. The main service offered is providing an extended access service, which included delivering the COVID-19 vaccination programme, with some non-NHS premises being designated as additional sites and providing additional GP appointments, screening capacity, and condition-specific services on behalf of Primary Care Doncaster’s member practices.
The provider also runs a health bus which is in operation Wednesdays, Thursdays and Fridays and is located in various areas of Doncaster each week, morning and afternoon to reach various population groups. The locations are advertised on the providers website and on social media and the services is accessible on:
- Wednesday 09:30 – 12:30 and 13:30 – 16:00
- Thursday 09:30 – 12:30 and 13:30 – 16:00
- Friday 9:30 – 12:30 and 13:30 – 16:00
How we inspected this service
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
- Conducting in-person staff interviews
- Requesting evidence from the provider
- Conducting a staff questionnaire
- Requesting and reviewing patient feedback
- A short site visit
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions therefore formed the framework for the areas we looked at during the inspection.
Updated
6 June 2022
This service is rated as
Good
overall. (Previous inspection 12 June 2019 – Requires improvement).
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Honeysuckle Lodge (formally registered as Devonshire House) to follow up on a breach of regulations. As part of the comprehensive inspection, we inspected safe, effective, caring, responsive and well-led.
CQC inspected the service on the 12 June 2019 and asked the provider to make improvements regarding Regulation 19 of the Health and Social Care Act etc. We checked this area as part of this inspection and found this had been resolved.
The provider, Primary Care Doncaster (PCD) is a GP federation located in Doncaster.
PCD has been commissioned to deliver 160 hours per week of primary care appointments, some of which are targeted at excluded and vulnerable groups. These are provided from a health bus which is in operation Wednesdays, Thursdays and Fridays at different sites in Doncaster, providing drop-in clinics. All practices in Doncaster will be able to signpost people to the health bus which is set up to service the whole population of Doncaster. All the GPs are regular locums.
Primary Care Doncaster also provide a COVID-19 vaccination service, this was not included in this inspection as they are not within scope.
Mrs Sherburn is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
As part of our inspection, we spoke with and received feedback from ten members of staff and received four comments from people who use the service.
Our key findings were:
- Staff had the information needed to deliver safe care and treatment.
- Staff worked together and with other organisations to deliver effective care and treatment.
- There was compassionate, inclusive and effective leadership at all levels. The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. Governance arrangements were proactively reviewed and had been significantly strengthened since the last inspection.
- There was a demonstrated commitment to best practice performance and risk management systems and processes.
- Staff at all levels demonstrated commitment to sharing data and information proactively to drive and support internal decision making as well as system-wide working and improvement.
- There was a clear, systematic and proactive approach to seeking out and embedding new and more sustainable models of care. For example, the health bus provides additional support to GP practices in Doncaster and reaches vulnerable people in society who have difficulty accessing healthcare.
- Staff said management were approachable, they felt supported, informed, listened to, there was an open-door policy and actions were taken for improvement. They also said it was a positive, inclusive, well-led and encouraging environment and staff work well together. They said PCD was a big family. Staff were proud of the organisation as a place to work and spoke highly of the culture.
- All the patient feedback was positive, and they spoke highly of the service.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care