Background to this inspection
Updated
26 October 2022
Dickens Place Surgery is located centrally in Chelmsford at:
830 Dickens Place,
Chelmsford
CM1 4US
The practice holds a General Medical Services (GMS) contract with NHS England. The GMS contract allows the practice to deliver primary care to the local communities. The practice has a list size of approximately 5,186 patients and provides GP services commissioned by Mid Essex Integrated Care Systems (ICS). An ICS is an organisation that brings together local GPs and experienced health professional to take on commissioning responsibility for local health services.
The practice is registered to provide the following regulated activities: diagnostic and screening procedures, family planning, maternity and midwifery and treatment of disease, disorder or injury.
The clinical team comprises six GP partners, three GPs, one practice nurse and one healthcare assistant. The clinical team are supported by a business manager and assistant practice manager and a team of receptionists and administration staff.
Appointments are available from 8am to 6pm Monday to Friday. Unscheduled out-of-hours and weekend care is provided by a local hub, a service set up by the Integrated Care Boards (ICB) and patients who contact the surgery outside of opening hours are provided with information on how to contact the service.
National data indicates that people living in the area are in the eighth most deprived decile of the deprivation scoring in comparison to England.
The practice has a comprehensive website providing information for patients to understand and access services, including useful contacts for specialist support services.
Updated
26 October 2022
We carried out an announced comprehensive inspection at Dickens Place Surgery on 27 September 2022. Overall, the practice is rated as good. This is the first inspection for this service.
The ratings for each key question
Safe - Good
Effective – Good
Caring – Good
Responsive - Good
Well-led – Good
Why we carried out this inspection
This inspection focused on:
- Safe, effective, caring, responsive and well-led services
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.
We found that:
- We found the monitoring of medicines and safety alerts were carried out in line with national guidance.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The practice had carried out a range of environmental risk assessments to ensure the safety of their staff and patients.
- The practice had safeguarding systems in place however safeguarding registers were not developed at the time of the inspection. Since the inspection, the practice had completed a safeguarding audit and introduced registers to highlight vulnerable patients.
- Although the practice had cold chain procedures in place, we found documentation was inconsistent. Since the inspection, the practice has reviewed and implemented changes to their procedures to ensure checks are completed in line with national guidance.
- The practice had engaged with local businesses to encourage the working age population to participate in national screening programs such as cervical screening.
- Patients received effective care and treatment that met their needs.
- We found a number of staff had not completed mandatory training. Since the inspection, the practice had reviewed their online training system and given staff time to complete the necessary training.
- We reviewed a number of staff files for clinical and non-clinical members of staff. We found that non-clinical staff members vaccinations were not noted in their files. Since the inspection, the practice had provided evidence of these checks.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- 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.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Strengthen safeguarding systems.
- Strengthen systems to ensure staff training is completed.
- Improve system to monitor cold chain procedures in line with national guidance.
- Continue to update vaccination records for non-clinical members of staff.
- Continue to improve the uptake for cervical screening.
- Improve patient satisfaction as highlighted in data from the National GP Patient Survey.
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 Hospitals and Interim Chief Inspector of Primary Medical Services