The Care Quality Commission
  • Doctor
  • GP practice

Denmark Road Medical Centre

Overall: Good read more about inspection ratings

37 Denmark Road, Winton, Bournemouth, Dorset, BH9 1PB (01202) 521111

Provided and run by:
Denmark Road Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Denmark Road Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Denmark Road Medical Centre, you can give feedback on this service.

5 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at Denmark Road Medical Centre on 5 December 2019, to check whether requirements made at our previous inspection in November 2018 had been met. The practice were required to make improvements to governance systems and ensuring staff were appropriately trained and supported.

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 and good for all population groups.

All requirements from the previous inspection have been met.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. 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:

  • Continue to improve monitoring of significant events to evidence timescales for any actions and detail the people who are responsible for any actions.
  • Continue to monitor and review outcomes for patients, in particular those for diabetes and hypertension.
  • Continue to review and address the uptake of cervical screening tests.
  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Review the complaints process to ensure information is consistently sent to complainants about other services they can use if they are not satisfied with the practice’s response.

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

01/11/2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating January 2017 – Good)

The key questions 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 carried out an announced comprehensive inspection at Denmark Road Medical Centre on 1 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen, but these systems were limited and did not provide full oversight, particularly in relation to safety alerts. When incidents did happen, the practice learned from them and improved their processes.
  • The completion and recording of training by staff was not fully embedded at the practice. This issue had also been identified at a previous inspection in April 2016.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice held regular multi-disciplinary meetings to discuss patients whose circumstances made them vulnerable.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use.
  • The practice had scored above local and national averages in the latest National GP Survey results.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Continue to improve the uptake for cervical screening to achieve the national target of 80%.
  • Review the security of external clinical waste storage.
  • Review arrangements for identifying and registering patients who are also carers.
  • Review how learning from significant events and learning events are shared with national reporting systems.
  • Review how patient participation feedback is used and their involvement in the practice considered.

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

6 December 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a focused inspection of Denmark Road Medical Centre on 6 December 2016 to check whether the practice had made the improvements in providing care and services that were safe, effective and well-led. The practice was able to demonstrate that they had made the required improvements to meet the regulations. The practice is now rated as good for safe, effective and well-led services. The overall rating for the practice is now good.

We had previously carried out an announced comprehensive inspection at Denmark Road Medical Centre on 19 April 2016 when we rated the practice as requires improvement overall. The practice was rated as good for being caring and responsive and requires improvement for safe, effective and well-led. This was because staff had been employed without the necessary recruitment checks and staff performing chaperone duties had not received the appropriate background checks. There were also gaps in the training which the practice considered necessary for staff. During the 19 April 2016 inspection we found that clinical areas containing blank prescription stationary and computer access cards were not secure. We also found that governance systems to adequately manage risks to patients and staff were not consistently followed thorough. Following our last inspection, we asked the provider to send a report of the changes they would make to comply with the regulations they were not meeting at that time. We received this on 30 August 2016. We revisited the practice on 6 December 2016 to check the improvements had been made.

Our key findings across the areas we inspected on 6 December 2016 were as follows:

  • Risks to patients were assessed and well managed.
  • Staff had been trained in order to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Staff received regular appriasals and appropriate pre-employment checks.
  • Staff performing chaperone duties had received appropriate training and background checks.
  • Clinical areas containing blank prescription stationary and computer access cards were secure.
  • There were effective governance arrangements in place in order to monitor the safety quality and performance of the practice.

This report should be read in conjunction with the full inspection report, which can be found at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Denmark Road Medical Centre on 19 April 2016. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and chaperone duties.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management.However, staff development plans and appraisals were not up to date.

  • We found there were gaps in the training staff needed to undertake their roles. For example, not all staff had received regular training in infection prevention control or basic life support.

  • The provider was aware of and complied with the requirements of the duty of candour.

We saw areas of outstanding practice:

  • One of the GP partners was qualified to perform in-house ultra sound scans on patients. The practice had purchased specialist equipment to enable the GP to perform around five scans per week. This reduced the length of time that patients had to wait to receive scans and referrals to specialists. The practice felt this also made referrals to specialists were more detailed and appropriate.

  • The practice had received an award in 2015 for the high quality of education and support that it provided to GP registrars.

  • The practice achieved consistently positive patient feedback. The most recent national GP survey results were consistently above local and national averages for patient satisfaction. Patient comments on CQC comment cards were also strongly positive about the practice. Patients we spoke to on the day of inspection spoke highly of the practice and of the high quality care they received.

However, there are areas where the provider must make improvement:

  • Ensure that staff undertake all training necessary for them to perform their roles such as infection control, safeguarding, health and safety, fire safety and basic life support.

  • Ensure that blank prescriptions held in clinical areas and staff access cards are kept securely at all times.

  • Ensure staff performing chaperone duties receive appropriate background checks.

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

  • Ensure that staff receive regular appraisals.

In addition, there are areas where the provider should make improvement:

  • Review the procedures for re-checking the frequency of background checks on staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice