We carried out an announced inspection at Downham Family Medical Practice on 30 June 2022. Overall, the practice is rated as requires improvement.
Set out the ratings for each key question
Safe – Requires improvement
Effective – Requires improvement
Caring – Not inspected, rating of good carried forward from previous inspection
Responsive – Not inspected, rating of good carried forward from previous inspection
Well-led – Requires improvement
At the last inspection, the caring and responsive key questions were rated Good. These ratings have been amalgamated with the ratings of this inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Downham Family Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this focused inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach. As part of the inspection there was a remote review of clinical records prior to the visit on 29 June 2022. We looked at Safe, Effective and Well Led key questions.
The data and evidence we reviewed in relation to responsive key question as part of our inspection did not suggest we needed to review the rating for Responsive and Caring at this time. The rating for Responsive and Caring remains rated as good.
How we carried out the inspection
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.
- 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 site visit.
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.
Safe is rated as requires improvement because:
- The provider did not always have adequate oversight of the risks associated with the areas of the building they occupied. For example, risks relating to the fire safety of the building. The provider did not routinely review historical safety alerts to ensure compliance.
- There were shortfalls in the management of infection prevention and control, specifically actions in response to the Legionella risk assessment.
- There was a process for recording and acting on significant events and staff could describe the process. However, only one event had been reported and investigated in the last 12 months.
- The process for reviewing historical safety alerts was not always effective.
Effective is rated as requires improvement because:
- The practice had implemented systems which supported the oversight of clinical care, for example a call and recall protocol. However, some areas required strengthening to ensure all patients with long-term conditions, received appropriate monitoring for their conditions.
- There was no effective system of documenting staff appraisals.
Well led is rated as requires improvement because:
- The arrangements for managing risk and oversight of governance did not always operate effectively.
- The provider did not keep all the necessary documentation, particularly for recruitment records, appraisals and staff did not routinely report incidents
We found breaches of regulations. The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas the provider should make improvements are:
- Continue to improve uptake for screening and immunisation programmes.
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