Background to this inspection
Updated
20 December 2021
Daleswood Health is an independent GP consulting service located in the village of Barston, near Solihull in the West Midlands. The service has been registered since May 2016 to deliver the following regulated activities: diagnostic and screening procedures; family planning; maternity and midwifery services; surgical procedures and treatment of disease, disorder or injury.
The service moved to Barn House in April 2017. The building has two floors, there are two entrances, one of which is suitable for wheelchair access. There are three consulting rooms on the ground floor and on the first floor there is an administrative office and an open area for meetings. There is an additional consulting room on the first floor used by the chiropodist. There is car parking available.
The service is a partnership of two GPs (one male and one female). One of the GP partners is also the Registered Manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Other staffing include a service manager/administrator and two reception staff. Daleswood Health also hosts a variety of services including physiotherapy, cognitive behavioural therapy, podiatry, lifestyle medicine and consultant surgeons.
The service is open from 8am to 8pm Monday to Friday and from 9am to 1pm on Saturdays. Appointments are also available outside of these hours by prior arrangement.
Patients accessed the service on a pay as you go or as part of a health plan arrangement.
Daleswood Health is not required to provide an out of hours service. Patients who need medical assistance outside core opening hours would need to contact the NHS 111 service or A&E if urgent.
How we inspected this service
During the inspection we spoke with staff, reviewed information made available to us by the provider, reviewed a sample of clinical records, made observations and obtained patient feedback through the CQC website.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions therefore formed the framework for the areas we looked at during the inspection.
Updated
20 December 2021
This service is rated as
Good
overall. (Previous inspection May 2019 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Daleswood Health on 15 November 2021 to pilot the changes to how CQC are monitoring services in response to the COVID-19.
CQC inspected the service on 15 May 2019 and rated the service as Good, there were no breaches in the regulatory requirements.
Daleswood Health provides an independent GP consulting service to children and adults of all ages.
This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in schedule 1 and schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Daleswood Health provides non-surgical cosmetic interventions which are not within CQC scope of registration. Daleswood Health services are also provided to patients under arrangements made by their employer a government department or an insurance provider with whom the servicer user holds an insurance policy (other than a standard health insurance policy. These types of arrangements are exempt by law from CQC regulation. Therefore, at Daleswood Health, we were only able to inspect the services which are not arranged for patients by their employers or a government department or an insurance provider with whom the patient holds a policy (other than a standard health insurance policy.
As part of the inspection, we received feedback from 42 patients via the CQC website. All were positive about the service. Patients described staff as professional, caring and kind. They told us that they received a timely service and enjoyed the continuity of care when needed.
Our key findings were:
- The service provided care in a way that kept patients safe.
- There were effective systems in place to protect patients from avoidable harm.
- Policies and procedures were in place to support the delivery of safe services.
- The premises and equipment were well maintained, risk assessments were undertaken to ensure the safety of patients and staff.
- The practice had systems and processes in place to minimise the risk of infection and had put in place additional measures during the COVID-19 pandemic.
- Appropriate checks were undertaken when recruiting new staff.
- Staff received appropriate training and guidance to deal with medical emergencies. The practice had risk assessed medicines and equipment they needed to stock in an emergency and had adjusted the medicines held since our previous inspection. However, the risk assessment did not mitigate against all recommended emergency medicines that were not routinely held.
- There were systems in place for identifying, acting and learning from incidents and complaints.
- Patients received effective care and treatment that met their needs. Our review of clinical records found appropriate care and treatment was being provided. Where appropriate the provider shared information with the patients NHS GP to support the safe care and treatment and continuity of care.
- The provider had invested in various diagnostic equipment including an ultrasound and mole mapping technology to support timely diagnosis and improved outcomes for patients.
- Patients were supported to live healthier lives, through education and support.
- Since our previous inspection we saw that the provider had undertaken quality improvement activity.
- Staff received appropriate training and competency checks and had annual appraisals to discuss any learning and development needs.
- Services available and fees were clearly displayed on the provider website.
- Staff treated patients with kindness and respect. Feedback obtained from patients was very positive about the service they received.
- Patient’s received timely care and treatment to meet their needs.
- Governance arrangements supported the delivery of safe and effective care.
We saw the following outstanding practice:
- The service provided point of care ultrasound scans. This had led to the early and timely detection of health conditions. The provider was able to provide several examples how this had impacted positively on patients outcomes which led to timely treatment for urgent and potentially life threatening conditions.
The areas where the provider should make improvements are:
- Include rationale and mitigation for all recommended emergency medicines not routinely stocked within the emergency medicines risk assessment.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care