We carried out an announced inspection at Darley Dale Medical Centre on 19 and 24 May 2022. Overall, the practice is rated as good. We rated the key questions:
Safe: Good
Effective: Good
Caring: Good
Responsive: Good
Well-led: Good
Darley Dale Medical Centre was previously registered at a different address. It was inspected on 1 November 2017 and rated Good overall and in all key questions. The previous report was archived in April 2019.
The full report for the previous inspection can be found by selecting the ‘all reports’ link for Darley Dale Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection because it has not been inspected at this location. The focus of our inspection included:
- All five key questions relating to safe, effective, caring, responsive and well-led.
How we carried out the inspection/review
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:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. Risk assessments were in place whilst the provider waited for the results of Disclosure and Barring checks for three new members of staff. However, a full list of vaccinations was not in place for one non-clinical staff member.
- In response to the findings from our remote searches action plans were put in place to mitigate potential risks to patients who had been prescribed medicines used in the prevention of stroke or medicines used to provide quick relief of asthma symptoms.
- Patients received effective care and treatment that met their needs. Three out of five indicators showed that the practice had achieved a 100% uptake rate in childhood immunisations. However, the cervical screening uptake rate was slightly below the national target of 80%.
- 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.
- There was a system in place to investigate and learn from complaints. However, the practice’s complaints policy was not always followed when acknowledging complaints.
- 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:
- Maintain records of vaccinations in line with current UK Health and Security Agency for all members of staff.
- Update and embed into practice the action plan for patients prescribed direct-acting oral anticoagulants so the calculation to monitor kidney function is completed dependant on need. Embed into practice their action plan to appropriately review patients prescribed over 12 short-acting beta-agonists (SABAs) inhalers in the last 12 months.
- Take appropriate action to increase their cervical screening rate to the national target of 80%.
- Follow their complaints policy to acknowledge complaints within three working days and inform patients of their right to contact the Parliamentary and Health Service Ombudsman if they were not satisfied with the response to their complaint.
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