This service is rated as Good overall. (Previous inspection July 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? – Requires Improvement
We carried out an announced comprehensive inspection at Durham Dales Health Federation as part of our inspection programme. This was the first time we had inspected this service at this address. We inspected the service under a different location’s registration (prior to them moving premises) in July 2019, when they were rated as good overall.
We looked at the key questions; is the service safe, effective, caring, responsive and well-led.
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:
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- Sending out and receiving questionnaires completed by staff working at the service
- A short site visit
On the day of the inspection we interviewed; the chief operations officer, the business support manager, the GP Medical Director/clinical lead, the clinical services manager, two advanced practitioner nurse leads, a GP, an advanced nurse practitioner and a receptionist at the providers sites.
Our finding
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 provider as good overall.
At this inspection we found:
- There were gaps in the oversight of some systems and processes to demonstrate effective governance. In particular, there were gaps in assurance around safeguarding training; the safety and effectiveness of premises; the risks of substances hazardous to health; infection prevention and control arrangements.
- The service had some systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
- The service routinely reviewed the effectiveness and appropriateness of the care they provided. They ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff had the skills, knowledge and experience to deliver effective care. However, assurances processes to check staff had received updated training in key areas was not always effective.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
- There was a focus on continuous learning and improvement at all levels of the organisation. However, some aspects of assurance in the governance framework had not operated effectively.
The area where the provider must make improvements as they are in breach of regulations is:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care