The Care Quality Commission
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Downham Family Medical Practice

Overall: Requires improvement read more about inspection ratings

7-9 Moorside Road, Bromley, Kent, BR1 5EP (020) 3838 8320

Provided and run by:
Downham Family Medical Practice

All Inspections

30 June 2022

During an inspection looking at part of the service

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.

This included:

  • 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.

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 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

16/09/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook an announced focused inspection of Downham Family Medical Practice on 16 September 2016. We found the practice to be good for providing safe care, and it is rated as good overall.

We had previously conducted an announced comprehensive inspection of Downham Family Medical Practice on 1 March 2016. As a result of our findings during that visit, the practice was rated as good for being effective, caring, responsive and well-led, and requires improvement for being safe. We found that the provider had breached Regulation 12 (1) (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; safe care and treatment.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focused inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Downham Family Medical Practice on our website at http://www.cqc.org.uk/provider/1-199742664.

Our key findings across all the areas we inspected were that the practice had met the legal requirements by having:

  • Purchased and installed oxygen to ensure that they were suitably equipped to manage medical emergencies. In addition the practice had added oxygen to the emergency medicines audit log to monitor the oxygen, created an oxygen management protocol, and staff had received training to ensure that they were familiar with the correct and safe use of the oxygen.

The practice had made additional improvements as follows:

  • They had improved their processes to ensure that significant events were recorded appropriately and that learning from these events was thorough.

  • GPs had received training to keep them updated on their responsibilities in relation to the Mental Capacity Act.
  • The practice had conducted audits of waiting times for two GPs. The audits identified reasons for any late running of appointments, wherever this had occurred, and they created an action plan to make appropriate improvements. They planned further audits of the waiting times of all GPs, to be completed by the end of December 2016.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

1 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Downham Family Medical Practice on 1 March 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events; however, some significant events had not been recorded appropriately and learning was not always thorough enough.
  • Risks to patients were assessed and well managed with the exception of the absence of oxygen for use in medical emergencies. After the inspection, the provider told us they would purchase oxygen.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Improvements had been made following a clinical audit; however, there was no evidence of a programme of continuous audits.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they did not always find it easy to make an appointment with a named GP, but urgent appointments were available the same day.
  • The practice had good facilities and was mostly well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

The area where the provider must make improvement is:

  • Ensure oxygen is available and all staff know how to use it.

The areas where the provider should make improvements are:

  • Review the system for recording and learning from significant events so it is robust.

  • Consider ensuring all clinical staff receive mental capacity training, and that any training received is documented.

  • Ensure patient feedback is continually reviewed and areas for improvement actioned where possible, particularly in relation to the availability of appointments and waiting times.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 July 2014

During a routine inspection

Downham Family Medical Practice is situated in a Health and Leisure Centre in a residential area of Bromley and is a practice within Lewisham CCG. 

The practice is registered by the Care Quality Commission to provide the regulated activities of Diagnostic and screening procedures, Family Planning, Surgical Procedures and Treatment of disease disorder or injury.

During our inspection we spoke with seven patients, and received twenty three comments cards which had been provided by the Care Quality Commission.  Patients were positive about the service. They said they received effective treatment by caring staff.

We spoke with six staff from a clinical and non clinical background who were able to demonstrate knowledge and competence for their area of professional responsibility at the practice.

We found that some improvements could be made to improve the safe delivery of the service. The staff team could do more to learn from incidents and events. Improvements were also needed to plan and monitor training for staff and ensure the recruitment procedure was robust.

The practice asked patients for their views and a Patient Participation Group (PPG) represented patients.  Efforts had clearly been made to build an effective PPG.