Danbury Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 1 quality statement from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. We found the practice leaders changed the governance systems at the practice and introduced patient safety meetings and a new management structure to help support the safe delivery of care. Staff were clear on their individual responsibilities and knew who was accountable for each aspect of the service.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders told us they had developed a new governance structure which was recently implemented which ensured a clear line of accountability. Staff told us they felt the leaders were approachable and they were comfortable to speak up. Staff we spoke with were clear on their individual roles and responsibilities but felt there were areas of staff shortage which impacted on the service provided.

The practice had reviewed their systems and processes and developed areas to help provide clear governance, quality assurance and risk management. There was a programme of meetings some of which were newly introduced to address such areas as significant events, complaints, recruitment, audits, the management of clinical concerns and long-term conditions. Audits had been conducted and used to help improve the service. For example, an audit of patients with atrial fibrillation and the prescribing of appropriate medicine between October 2022 and February 2023; a cancer screening audit in autumn 2023 which demonstrated the practice screened more patients with a learning disability for bowel and cervical cancer than the national average. Although an action plan was in place, and issues identified during the assessment were addressed by the practice, these new processes had not had sufficient time to show they were fully embedded and sustainable. The practice had implemented a structure to learn from significant events, to identify action to be taken regarding MHRA alerts and to take action regarding the CQC GP specialist advisor search results. A system of support was identified for the referral process. Action had been taken to address access concerns, however, patient satisfaction with access to the practice and appointments remained low. The practice had a Business Continuity Plan & Policy and had completed a data security and protection toolkit.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.