Devonshire Green Medical Centre

Background to this inspection

Updated 2 August 2017

Devonshire Green Medical Centre is located in a purpose built health centre in inner city Sheffield with a branch site known as Hanover Medical Centre located in the Broomhall area of Sheffield. The practice accepts registration from patients of the surrounding areas. We visited both sites as part of this inspection.

Recent practice data confirmed 20% of patients on the practice register had been registered homeless and there was a high number of patients where English was not their first language. Public Health England data shows the practice population has a higher than average number of patients aged 0 to 55 years old compared to the England average. The practice catchment area has been identified as one of the third most deprived areas nationally.

The practice provides General Medical Services (GMS) under a contract with NHS England for 7,080 patients in the NHS Sheffield Clinical Commissioning Group (CCG) area. It also offers a range of enhanced services such as anti-coagulation monitoring and childhood vaccination and immunisations.

Devonshire Green and Hanover Medical Centres have five GP partners (four female, one male), three female practice nurses, one healthcare assistant, a practice manager, senior administrator and an experienced team of reception and administration staff. The practice is a teaching and training practice for medical students, GP registrars, nurse students and physician associates.

Devonshire Green Medical Centre is open 8.30am to 6pm Monday to Friday with the exception of Thursdays when the practice closes at 12 noon. The branch site at Hanover Medical Centre is open 8.30am to 6pm Monday to Friday with the exception of Tuesday and Thursday when the branch closes at 12 noon. The GP Collaborative provides cover when the practice is closed on a Thursday afternoon. Morning and afternoon appointments are offered daily Monday to Friday with the exception of Thursday afternoon when there are no afternoon appointments.

When the practice is closed between 6.30pm and 8am patients are directed to contact the NHS 111 service. The Sheffield GP Collaborative provides cover when the practice is closed between 8am and 6.30pm. For example, at lunchtime. Patients are informed of this when they telephone the practice number.

As part of the Care Quality Commission (Registration) Regulations 2009: Regulation 15, we noted a change to the registered details of the service in that the branch site at Hanover Medical Centre was registered as a separate location and not included on the registration of Devonshire Green as a branch. The partners identified on the partnership did not reflect the partners in the practice. The practice manager told us notifications had been submitted and the practice were in the process of completing the application forms.

Overall inspection

Good

Updated 2 August 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Devonshire Green Medical Centre and the branch site at Hanover Medical Centre on 9 November 2016. The overall rating for the practice was requires improvement with requires improvement in safe and well led. The full comprehensive report from 9 November 2016 can be found by selecting the ‘all reports’ link for Devonshire Green Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 July 2017 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 at our previous inspection on 9 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good. Specifically, following the focused inspection we found the practice to be rated good for being safe and well led.

Our key findings were as follows:

Recruitment checks to ensure staff were of good character had been completed. All clinical staff and staff who performed chaperone duties had received a Disclosure and Barring Service (DBS) check and there were references on file for new staff recruited since the last inspection.
All staff had received safeguarding training relevant to their role as recommended in the Safeguarding Children and Young people: Roles and Competencies for Healthcare Staff 2014.
All staff had received basic life support training as recommended in the Resuscitation Council (UK) Guidelines for staff working in a primary care organisation.
The fire risk assessment had been reviewed. A fire drill had been carried out at both sites and maintenance checks of the fire alarm system were more regular although did not comply with the practice's Fire Safety Policy of being completed weekly at the Hanover Medical Centre site. These had been completed weekly at the Devonshire Green site.
The legionella risk assessment had been reviewed and actions taken to mitigate the risks identified.
A process to action safety alerts received by the practice had been implemented. However, there was no monitoring overview of these.
A training matrix had been implemented to monitor what training staff had received and when it was due to be updated.
.A system to monitor that clinical staffs’ registration with their professional body and medical indemnity cover for clinical staff was adequate and in date had been implemented.
Cleaning schedules had been implemented to monitor what cleaning had taken place and the frequency.

Areas the practice should improve:

The practice should implement a central log or monitoring overview of safety alerts received and action taken for staff to reference.
The practice should carry out maintenance checks in line with the Fire Safety Policy.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice