The Old Dairy Health Centre

We carried out an announced focused review of The Old Dairy Health Centre on 23 December 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous comprehensive inspection on 6 June 2019, the practice was rated Good overall. This inspection focused on the five key questions: Safe, Effective, Caring, Responsive and Well-led. The practice was rated as requires improvement for providing Safe services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Old Dairy Health Centre on our website at www.cqc.org.uk

Why we carried out this review

This review was a focused review of information without undertaking a site visit inspection, to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection. This report covers our findings in relation to those requirements and also improvements made since our last inspection.

At our previous inspection we found care and treatment was not provided in a safe way for service users;

• The provider had failed to ensure the proper and safe management of medicines;
• The provider had not followed guidelines for management of infection control.
• Staff did not have all of the information they needed to ensure that safe care and treatment were delivered.
• Systems were not in place to keep people safe: The service stored liquid nitrogen on the premises. The room in which the cylinder was stored had no windows and was not ventilated, and the service had not risk assessed how it was stored.
• The service was not able to show that references had been received and reviewed prior to the recruitment of some staff at the service.

We also asked the practice to;

• Ensure the route by which complaints might be escalated is included in the reply to letters.
• Review how records of staff training are maintained.
• Review how safety alerts are accessed, including details of actions taken.

How we carried out the review

We requested evidence from the provider and reviewed the information provided, without undertaking a 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.

The practice is now rated as Good for providing safe services. The overall rating remains unchanged from our previous inspection. 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.
• The practice had improved the system to monitor infection prevention and control.
• The practice had taken action to improve the management of test results. There was an improved system in place to ensure that urgent or abnormal results were followed up effectively.
• The practice had reviewed its policy for the storage of hazardous substances for example, liquid nitrogen. Staff had risk assessed the area of the premises used to store liquid nitrogen.
• The practice had made the improvements we asked them to make to the accessibility of the complaints process.
• Maintenance of staff training records had improved. The practice had reviewed and updated their recruitment policy to ensure recruitment checks were carried out in accordance with regulations.
• The practice provided evidence of actions taken to improve the system for managing safety alerts. The practice maintained a central log of alerts including details of actions taken.

We also reviewed the areas we identified where the provider should make improvement:

• The practice had reviewed how patients were informed about how to make a complaint. Staff had ensured that the route by which complaints might be escalated to the Health Service Ombudsman was included in the reply to letters. We saw that this information was provided in the practice complaints leaflet.
• The practice had ensured the practice complaints policy was available to patients in the reception area.
• The practice had reviewed its safety alerts policy.
• There were clear systems for checking that all staff in the practice were up to date with training.

Whilst we found no breaches of regulations, the provider should:

• Continue to embed systems to ensure regular risk assessments are undertaken and reviewed to monitor quality and performance and to encourage improvement.

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 Hospitals and Interim Chief Inspector of Primary Medical Services