The Care Quality Commission
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  • GP practice

Archived: Blue Dykes Surgery Also known as Drs Wayman & Shell

Overall: Good read more about inspection ratings

Eldon Street, Clay Cross, Chesterfield, Derbyshire, S45 9NR (01246) 866771

Provided and run by:
Blue Dykes Surgery

Important: The provider of this service changed. See new profile

All Inspections

8 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Blue Dykes Surgery on 8 June 2016. Overall the practice is rated as good.

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

  • Significant improvements had been made to the systems and processes in place which was highlighted following our initial inspection in August 2015. This included arrangements for delivering safe care and treatment and improved governance arrangements.

  • Risks to patients and staff were well monitored and regular audits carried out to ensure policies reflected the latest guidance.

  • The practice had an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • An innovative approach to staffing had established an effective clinical team which had areas of specialties allowing the most appropriate clinician to care for patients. For example, the practice employed a community psychiatric nurse, two pharmacists and advanced nurse practitioners in addition to practice nurses and a health care assistant.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice undertook clinical audits to review patient care and took action to improve services as a result. A plan was in place for future audits and all staff were actively involved in driving improvement.

  • Patients told us that access to GP appointments could sometimes be difficult and this was reflected in the results from the national GP patient survey.

  • Information about services and how to complain was available. The practice sought patients’ views about improvements that could be made to the service directly and through the patient participation group (PPG).

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

  • In spite of the improvements there were some areas where governance and oversight needed to be strengthened, for example ensuring staff training the practice deemed mandatory had been completed by all staff.

  • The practice planned and co-ordinated patient care with the wider multi-disciplinary team to deliver effective and responsive care for patients with complex health needs and / or living in vulnerable circumstances.

  • The practice had an active PPG and worked with them to review and improve services for patients.

However there were areas where improvements should be made:

  • Ensure an effective system is in place to ensure training, which the provider deemed as mandatory, is completed by all staff.

  • Ensure patient experience data (including access to appointments) continues to be reviewed, monitored and acted upon to continually drive service improvement.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

4 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Blue Dykes Surgery on 4 August 2015. Overall the practice is rated as requires improvement. Specifically, we found the practice inadequate for providing safe services. It was rated as good for providing, effective, responsive, and caring services and requires improvement for being well led services. The evidence which led to us rating the practice requires improvement potentially affects all population groups and we have therefore rated older people , people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental (including people with dementia) as requires improvement. Our key findings across all the areas we inspected were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

  • At the time of the inspection, patients were at risk because there was insufficient clinical capacity to ensure key tasks were undertaken in a timely manner and by staff who had the appropriate clinical skills to make safe decisions. This included taking action in response to letters and making changes to medicines as requested by secondary care and triaging letters coming into the practice from other providers. The practice immediately addressed this issue and cleared the backlog of correspondence.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

  • Urgent appointments were available on the day they were requested. Patients said that they sometimes had to wait a long time for non-urgent appointments with a GP of their choice.

  • The recruitment processes were not robust and did not ensure that patients received care and treatment from staff who had been fully checked to confirm they were suitable to work with them.

The areas where the provider must make improvements are:

  • Ensure there are effective systems designed to identify, assess and mitigate against risk, for example in respect of concerns with infection prevention and control.

  • Ensure that there are effective systems in place to assess and monitor the quality of the service being provided; for example by ensuring audits of practice are undertaken, including completed clinical audit cycles.

  • Ensure processes to deal with clinical letters from other agencies, detailing the changes needed to patient’s medications are robust, actioned timely and by the appropriate staff.

  • Ensure a system is in place to give oversight ensuring all the required employment checks are carried out for all staff to ensure they are suitable to work with patients.

  • Ensure that all staff are trained appropriate to their role and that training records are kept.

  • Ensure robust systems are in place to manage and store stocks of medicines to minimise the risk of out of date medicines and dressing being used.

  • Strengthen the system that would ensure that learning from significant events, and near misses was recorded, learning shared, and improvements made.

In addition the provider should;

  • Ensure that the practice has an approved safeguarding policy implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice