Denmark Road Surgery

We carried out an announced comprehensive inspection at Denmark Road Surgery on 23 October 2019 to follow up on the breaches of regulations identified in the last inspection (March 2019).

This service was placed in special measures in October 2018 and remained in special measures following the last inspection in March 2019.

At the last inspection in March 2019 we rated the practice as requires improvement overall and Inadequate in well-led because:

• The risks associated with the practice premises that had not been well managed.
• Some performance data was significantly below the local and national averages and national targets.
• There was not sufficient monitoring to ensure that changes made to telephone access to the practice had improved the patient experience.
• The practice was not responding effectively to patient feedback.
• There was insufficient leadership of some areas of practice governance, particularly related to patient safety.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.

At this inspection, we found that the provider had addressed most of these areas; however, we identified some new issues.

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 overall and requires improvement for the population groups older people, families, children and young people and working age people.

We found that:

• The systems and processes in place to keep patients safe required improvement. For example, the provider did not have a robust system in place for the management of medicines. Staff had not completed safeguarding training relevant to their role.
• Patients received effective care and treatment that met their needs; however, the provider did not have an effective system to ensure regular medicines reviews were undertaken for patients. The uptake for cervical screening and childhood immunisations were below average.
• Staff dealt with patients with kindness and respect and patients we spoke to indicated that they were involved in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. However, some of the patients we spoke to indicated it was difficult to get appointments.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care; however, governance systems in place required some improvement.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review antibiotic prescribing.
• Review procedures in place to demonstrate improved outcomes for patients.
• Consider ways to improve uptake for childhood immunisations, bowel cancer screening and cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

CQC carried out an announced comprehensive inspection of Denmark Road Surgery on 5 March 2019 to follow up on breaches of regulation identified in August 2018. The practice was rated as requires improvement overall with ratings of requires improvement for providing safe, effective and responsive services, good for providing caring services and inadequate for providing well-led services. As a result of the findings on the day of the inspection the practice was issued with a warning notice for breach of Regulation 17 (Good governance). You can read our findings from our last inspections by selecting the ‘all reports’ link for Denmark Road Surgery on our website at

This was an announced focused inspection on 12 June 2019. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements as detailed in the warning notices issued on 03 April 2019.

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.

This inspection was an unrated inspection to follow up on warning notices and the rating remains unchanged.

At this inspection we found:

• Significant events were discussed and lessons learnt in a timely manner. The provider was aware of the requirement to make notifications to the Care Quality Commission and had updated their incident policy accordingly.
• The recruitment policy was updated to reflect national guidance. The pre-employment risk assessment was updated to ensure it is fit for purpose. The provider had undertaken the required recruitment checks for staff recruited since the last inspection.
• Staff training matrix had been updated to include the correct level of training required for staff.
• The provider had put a system in place to monitor the expiry dates of vaccines and emergency medicines, which we saw was being followed.
• The provider had reviewed the policies and procedures in place and had removed duplicates. The whistleblowing policy had been updated to reflect national guidance. The staff handbook had been updated to include the procedures in place.
• The infection control policy had been updated to include the lead name and to bring in line with the staff immunisation policy; the infection control lead had completed appropriate training. The provider had undertaken an infection control audit in May 2019 and had completed the recommended actions for their service.
• The business continuity plan had been updated to include the contact details of NHS Property Services.
• All risks were recorded on the risk register which was part of the COSHH and risk management protocol.
• The provider had completed most of the actions following the fire risk assessment carried out on behalf of NHS Property Services in November 2018. The provider had undertaken another fire risk assessment on June 2019 and had completed the recommended actions relevant to their service. The provider informed us they were in regular contact with NHS Property Services and were following up on the actions NHS Property Services had to complete.
• The provider showed us evidence of completion of urgent actions following the Legionella risk assessment carried out on behalf of NHS Property Services in April 2018; they showed evidence of quotes obtained to address medium risk actions.
• The provider had put a system in place to receive, implement and monitor the implementation of medicines and safety alerts.
• The provider had undertaken a revised telephone survey and were using the monitoring functions of the phone system to monitor performance. The provider informed us they regularly discussed and monitored incoming telephone calls including the number of calls answered, unanswered, abandoned or engaged; we saw evidence to support this. The provider informed us they had regular contact with the telephone provider and had recently increased the number of incoming lines to improve telephone access for patients; they informed they still are waiting for support from the telephone provider to perform more analysis of incoming telephone calls.
• The practice had analysed the results of the friends and family test and discussed the results in meetings to make improvements.
• The provider failed to achieve the 90% target for childhood immunisations for 2018-19. The provider had an action plan in place to improve uptake; they recently had designated a member of administrative staff to call and offer appointments to these patients.
• In 2018 the provider had not achieved the 60% target for bowel cancer screening and had only achieved 49%. The provider had an action plan in place to improve uptake; the practice sent additional letters to patients to remind them to undertake this screening. The practice had setup alerts for patients over the age of 60 and when these patients attend for appointments in the practice the clinicians educated and encouraged them to undertake this screening.
• In 2018-19 the provider had undertaken learning disability health checks for 75% (25 patients). Following the last inspection, the provider had undertaken these checks for four additional patients and had booked one patient for this check a week following the inspection. In the current year the provider had already undertaken health checks for eight patients.

The areas where the provider should make improvements are:

• Review practice procedures to ensure all the recommendations from the fire and legionella risk assessments are actioned.
• Continue to improve uptake for bowel cancer screening, childhood immunisations and learning disability health checks.

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

We carried out an announced comprehensive inspection at Denmark Road Surgery on 5 March 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 15 August 2018, where the practice had been rated as inadequate, with safe, effective, and well-led domains rated as inadequate, and caring and responsive domains rated as requires improvement. At this inspection we found that there remained insufficient leadership of practice management to ensure consistent and effective governance. The practice therefore remains rated as inadequate for being well-led, and remains in special measures.

We first inspected the practice in December 2016 where the safe and well-led domains were rated as good. We did not rate the effective, caring or responsive domains as at that time the provider did not have any external performance data.

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 overall.

We rated the practice as requires improvement for providing safe services because:

• The practice had strengthened a number of systems and processes to manage risks to patients.
• However, some of those systems were not operating effectively and so there remained some risks, particularly associated with the practice premises, that had not been well managed.

We rated the practice as requires improvement for providing effective services because:

• Staff had received training and support required for their role.
• The practice had implemented action plans to address areas where patients did not receive good care and treatment.
• However, some performance data was still significantly below local and national averages/national targets.

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services because:

• There was not sufficient monitoring to ensure that changes made to telephone arrangements had improved the patient experience.
• The practice was not responding effectively to patient feedback.

These areas affected all population groups so we rated all population groups as requires improvement.

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

• Although the practice had made improvements since the last inspection, there remained insufficient leadership of some areas of practice governance, particularly related to safety.
• There were a number of systems that had incomplete or inaccurate data or were not operating effectively.
• The practice had improved its clinical performance, but some areas were still below average or below target.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We served warning notices following the last inspection for breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The inadequate rating takes into account the evidence from this inspection and the fact that the provider has not fully rectified the issues following the previous enforcement action.

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:

• Take action to improve how young patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

This service was placed in special measures in October 2018. Insufficient improvements have been made such that there remains a rating of inadequate for a key question. Therefore, we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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