Delapre Medical Centre

We carried out an announced comprehensive inspection at Delapre Medical Centre from 26 June 2023 to 5 July 2023. Overall, the practice is rated as Inadequate.

Safe - Inadequate.

Effective – Requires Improvement.

Caring – Good (rating carried over from previous inspection)

Responsive – Good.

Well-led – Inadequate.

Why we carried out this inspection

Following our previous inspection on 2 March 2016, the practice was rated as good overall and for all key questions. We carried out this inspection in line with our inspection priorities. The risk had increased for this service as we identified some concerns through our monitoring activities of the practice.

The full reports for the previous inspections can be found by selecting the ‘all reports’ links for Delapre Medical Centre on our website at www.cqc.org.uk

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing facilities.
• 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.
• A short site visit of the practice and branch site.

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 inadequate overall.

We rated the provider as inadequate for providing safe services:

• Systems or processes were not established and operating effectively to assess, monitor and mitigate risks relating to the health, welfare and safety of service users. In particular, risks associated with staff undertaking chaperoning duties without a Disclosure and Barring Service (DBS) background check, had not been assessed. Nor had risks associated with the absence of appropriate health and safety checks for electrical, gas and water safety been assessed.
• There was no assurance on the immunity and vaccination status of staff employed to ensure risks to themselves and patients were minimised.
• There were gaps in infection prevention and control (IPC) systems. We found IPC standards were not always met.
• Safety procedures for fire were not adequate.
• Medicines management arrangements were insufficient.
• Systems for managing test results were ineffective.
• Staff were not always aware of action to take to report significant events.
• Safety alerts were not appropriately actioned.

We rated the provider as requires improvement for providing effective services:

• We found gaps in systems to support some patients with long term conditions.
• We found evidence to demonstrate all patients taking medicines that required routine review were not receiving adequate care.
• Childhood vaccinations were below national targets.
• The practice had not met the national target for uptake of cervical cancer screening.
• There was no evidence of targeted quality improvement, for example through regular clinical audit.
• There was insufficient oversight of staff training, with evidence that multiple staff had not completed mandatory training (as designated by the practice).
• Not all staff received regular appraisals and there was no evidence of formal clinical supervision for non-medical prescribers.
• There was no embedded approach to managing and supporting patients with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) to demonstrate the practice maintained effective oversight of DNACPR decisions.

We rated the provider as good for providing responsive services:

• The practice identified a high prevalence of patients with complex mental health needs and responded by recruiting two dedicated mental health nurses.
• In an effort to improve patient experience the practice had invested in an e-consultation tool to support patients in accessing appropriate care. Steps were taken to ensure all patients, including those who were digitally excluded were still able to access care.

We rated the provider as inadequate for providing well-led service:

• There was a lack of clear responsibilities, roles and systems of accountability to support good governance.
• There were gaps in polices and protocols which resulted in an inconsistent approach in the management of risks.
• There was ineffective governance and clinical oversight to provide an adequate and safe service for service users.
• There were insufficient systems and processes established and operating effectively to assess, monitor and mitigate risks relating to the health, welfare and safety of service users.
• Staff feedback on the visibility and support offered by senior management and GPs was mixed.

We found two breaches of regulations, the provider must:

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

In addition, the provider should:

• Continue to monitor the efficacy of recently introduced systems to manage blank prescription safety.
• Take steps to improve uptake of childhood immunisations.
• Continue to encourage and engage patients to attend for cervical screening.

Due to the breaches of regulation identified we will be carrying out further enforcement action against the provider.

I am placing this service in special measures. The Care Quality Commission will refer to and follow its enforcement processes in taking action reflecting these circumstances.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted.

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 Health Care