Latest CQC Summary

The CQC Inspection of Primary Care Doncaster’s Extended Access Service in 2019 resulted in an overall rating of “Requires Improvement”. Below are the reasons why this rating was given, and what PCD have done since to rectify the issues. The work we’ve done means we are now confident that when we are re-inspected, the rating will be changed to “Good”. 


CQC rated the service as requires improvement for providing SAFE services because: What we have done to fix this:
•    There was a lack of evidence all staff had received the appropriate level of safeguarding training.The certificates are now centralized from Target sessions and sent to clinicians and we hold this record and provide it to HR when requested. For clinicians not local to Doncaster, we require evidence of safeguarding training as part of our mandatory pre-employment checks. 
•    There was a lack of evidence all the required recruitment checks had been undertaken.We employed an HR administrator full time in order to ensure that recruitment checks are robust and the policy has been updated and adhered to at all times
•    Provision of emergency equipment and medicine at inclusionclinics was not based on risk assessment.Risks assessments were carried out for all inclusion clinics and the health bus to identify the need for emergency medications and equipment needed. These are now in place and a robust system is set to check them monthly
CQC rated the service as requires improvement for providing EFFECTIVE services because: What we have done to fix this: 
•    There was a lack of evidence the practice ensured staff had received relevant training, including refresher training, for theirrole.This again is highlighted in the employment checks and different job descriptions have been developed for each type of clinical role. There is a robust HR process around competencies and when they are due to expire and no professional can take a shift or be employed until this is complete.“How to” guides have been developed and implemented ensuring all clinicians are informed of processes at the clinics relating to clinical care, risk and governance issues
•    There was a lack of evidence of quality monitoring and improvement relating to clinical outcomes.Our sub-contractors (FCMS/Chapmans Physiotherapy) audit their services and feed this back to PCD. There is now a process for clinical audit of services delivered by PCD staff, with dedicated GP resource allocated to this.We hold regular meetings with practice hub managers and also with our inclusion health partners, to monitor adherence to the Memoranda of Understanding which have now been agreed. These MoU include processes for carrying out Infection Prevention Control procedures and checks relating to the Inclusion health clinics, ensuring standards are met as per PCD policy. Drug checks at all Inclusion Health clinics are carried out to check expiry dates and equipment checks.Significant Event Analysis meetings take place within PCD at both committee and operational level in order to maintain standards and reduce risks. 
CQC rated the service as requires improvement for providing WELL LED services because:What we have done to fix this:
•    The service lacked effective processes to monitor the provision of services by other organisations such as recruitment and infection prevention and control compliance.We have a full time Chief Nurse to carry out and oversee IC policies for each inclusion health clinic and health bus.Full documentation of the regular cleaning schedule is now in place. Regular audits are in place to monitor the effectiveness, which are transparent and well documented
•    While several areas had been identified for improvement, such as clinical audit and staff training, systems to improve these areaswere in very early stages of development.As above – the systems are now developed and in place in order to maintain clinical effectiveness and patient safety
•    Some areas had not been risk assessed such as emergency equipment and medicines provision and transport of blank prescriptions and patient records.All the risk assessments are now in place and the medication provision work is complete and being monitored. There is a process to store blank prescriptions between their use and the transport of patient records is now comprehensively mitigated. Patients whose existing record cannot be accessed by the team have their notes entered electronically into the clinical system under an “immediately necessary” new record, and therefore all patient records are electronically managed without the existence of paper records. All administrators and clinicians are trained in this process and made aware of PCD policy upon commencing employment.