We carried out an announced comprehensive inspection at Denham Medical Centre in Buckinghamshire on 2 April 2018 as part of our inspection programme.

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 all population groups.

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

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The practice had appropriate systems in place for the safe management of medicines.

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

• With the exception of patients with learning disabilities, outcomes of care and treatment was monitored. The management of urgent test results was robust and the practice was proactive in ensuring patients received the urgent care and treatment as quickly as possible.

• The practice could show that staff had the skills, knowledge and experience to carry out their roles.

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.

• The practice organised and delivered services to meet patients’ needs including the provision of services for people with caring responsibilities.

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

• Complaints were not handled in accordance with regulations. We found systems and processes for managing complaints were in place however, these were not used effectively.

• Patients said they had timely access to services, the appointment system was easy to use and the information technology available supported their access to services.

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

• The arrangements for governance were not operated effectively. It was unclear which governance arrangements, strategies or plans had been reviewed.

• Staff morale and feedback was mixed.

• There was limited engagement with patients. For example, there had not been a recent patient survey and there was no active Patient Participation Group (PPG) in place.

The areas where the provider must make improvements are:

• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• 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).

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Denham Medical Centre on 20 April 2016. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for provision of safe and effective services. It was good for providing caring, responsive and well-led services. The concerns which led to these ratings apply to all population groups using the practice.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. The majority of information about safety was recorded, monitored and reviewed.
• Risks to patients and staff were assessed and well managed in some areas, with the exception of those relating to fire safety and safeguarding children and adults training. For example, the practice did not develop written action plan with clear time scales to address the high risk issues identified during recent fire safety risk assessment carried out on 29 June 2015.
• We found that completed clinical audits cycles were driving positive outcomes for patients.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However, most staff had not completed health and safety, equality and diversity, fire safety and infection control training.
• Results from the national GP patient survey showed majority of patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment when compared to the local and national averages. The majority of patients we spoke with on the day of inspection confirmed this.
• Information about services and how to complain were available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP, 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. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Develop written action plan with clear time scales to address the high risk issues identified during recent fire safety risk assessment.
• Ensure all staff have undertaken training including safeguarding children and adults, health and safety, equality and diversity, fire safety and infection control.
• Review and monitor the system in place, to improve the outcomes for patients with learning disabilities.

In addition the provider should:

• Ensure national safety and medicines alerts and National Institute for Health and Care Excellence (NICE) best practice guidelines are followed up systematically after they are disseminated within the practice, to monitor that required changes have been implemented.
• Ensure all necessary recruitment checks are in place including systems for assessing and monitoring risks, carrying out Disclosure and Barring Scheme (DBS) checks or risk assessment.
• Review patients feedback and address concerns identified on the national GP patient survey regarding GPs listening, giving enough time, involving in decisions, and explaining tests and treatments during consultations.
• Review patients feedback regarding the introduction of pre-bookable online appointments.
• Review and monitor the governance arrangements in place to ensure the delivery of safe and effective services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

In April 2016, during our previous comprehensive inspection of Denham Medical Centre, we found issues relating to the safe and effective delivery of healthcare services. The practice also needed to review and monitor their governance arrangements. As a result of this inspection, we asked the practice to make further improvements; in order to address the high risk issues identified during their most recent fire safety risk assessment; ensure national safety and medicines alerts and National Institute for Health and Care Excellence (NICE) best practice guidelines were followed up systematically; undertake all necessary recruitment checks to carry out Disclosure and Barring Scheme (DBS) checks or risk assessments; and ensure all staff had undertaken essential training such as safeguarding children and adults.

Furthermore, the practice also needed to review and monitor the system in place to improve the outcomes for patients with learning disabilities; review patients’ feedback and address concerns identified from the national GP Patient Survey regarding the GPs and the introduction of pre-bookable online appointments.

Following the last inspection, the practice was rated as requires improvement in safe and effective services, and good for caring, responsive and well led services. The practice had an overall rating of requires improvement.

We carried out a desk based inspection in November 2016 to ensure the practice had made improvements since our last inspection. The practice sent us evidence in the form of a fire quality assurance report, a staff training log, bluestream academy (bluestream is a type of online training for healthcare providers and professionals) reports, a learning disability appointments record and evidence of a learning disability database search carried out by the practice.The practice also further supplied a chart outlining the areas the practice had changed to make improvements. We found the practice had made some improvements since our last inspection in April 2016.

At this inspection we found that:

• The practice had taken steps to address the high risk issues identified during their previous fire risk assessment.

• The practice had provided a copy of a quality assurance report produced by an independent company.

• Steps were taken by the practice to address issues surrounding GP and administrative staff training in adult safeguarding and child protection.

• The practice had provided evidence of staff training by supplying bluestream academy reports, and a copy of a staff training log.

• Policies and procedures for Disclosure and Barring Scheme (DBS), and the recruitment of new staff were provided.

• Steps were taken by the practice to review patient feedback.

The areas where the provider should make improvements are:

• Continue to review and monitor the system in place, to improve the outcomes for patients with learning disabilities.

• Ensure the governance arrangements in place for the delivery of safe and effective services are fully embedded.

Following this desk based inspection we have rated the practice as good for providing safe and effective services. The overall rating for the practice is good. This report should be read in conjunction with the full inspection report of 20 April 2016. A copy of the full inspection report can be found at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice