Care Quality Commission (CQC)


In November 2014 as part of its new approach to monitoring GP practices the CQC launched GP Intelligent Monitoring (IM) system. It is a system which helps them prioritise inspections. They look at 37 indicators that are made up of different types of evidence on patient experience, care and treatment based on sources including surveys and national statistics data. It is used to prioritise how soon they need to undertake  inspection of a practice.  CQC state they can only judge the quality of care once a practice has been inspected by them.  CQC are looking for practices that provide safe, caring, effective care that is responsive to patients needs and that are well led. These are all ideals that we strive to achieve at Dysart.

The CQC give a band rating from 1-6. Band 1 representing the highest priority for inspection and band 6 the lowest. Our practice is classed as band 3 priority for inspection.

Each practice is given a risk score out of 74. The worst possible risk score is 74 out of 74 and the best risk score is 0 out of 74. Our risk score at Dysart was 4 out of 74. In our practice from Intelligent Monitoring  CQC identified 4 areas where we could perform better. These are:

1)The percentage of our  patients aged over 6 month to under 65 who have received flu that should have had it in 2013

2)The percentage of our patients with diabetes who have had the flu vaccine between 1\4\2013-31\3\2013

3)The proportion of respondents who stated that in the reception area other patients cant hear what they’re saying

4)The percentage of people who were very satisfied or fairly satisfied with the GP opening hours.


Flu vaccination is available every year to protect those at risk of flu. We invite all those over 65 or patients who have asthma, diabetes, chronic heart disease or lung disease to have the Flu vaccine. We offer appointments at weekends in our flu clinics or in the week to maximise the convenience of having the vaccination. Our district nurses offer all our housebound patients who are unable to get to the surgery flu vaccinations in their homes. We have actively looked at ways to optimise our flu targets this year whilst at the same time being mindful of the fact that we can recommend flu to our patients but it is their choice whether they accept our offer or not.

We were disappointed to hear that patients felt overheard in the reception area of our practice and very much apologise for this. The reception area at Dysart is small and cramped and is in close proximity to the waiting room. Last year, we removed the glass panel that separated our reception desk from patients so that conversations between our patients and receptionist would be easier. We have started playing music in the waiting area so that conversations at the reception desk cannot be overheard.  We have placed a sign in reception letting patients know that that if requested they are able to speak to a receptionist privately in a separate room.  We are currently in discussion about expanding our current premises and if this is successful maximising the confidentiality of our reception desk will be a priority area. We hope that the other measures we have introduced will optimise the privacy of the reception desk in the meantime.

In terms of our opening hours we currently have core hours of surgery  8.30am – 6.30 pm.  Our phone lines are answered from 8 am-6.30 pm. We offer extended hours to our patients between 7-8 am on Wednesday and 8.50am -11.30 am on a Saturday. We have discussed how we could advertise our extended hours better and now advertise our extended hours opening both on our website and in a prominent place in reception. We have also introduced telephone consultations so that if a patient is not able to come to the surgery during the opening times they can have the opportunity to consult with us over the phone.

We hope this is helpful to outline the summary of the Intelligent Monitoring carried out by the CQC.  We are hugely proud or our practice but are aware that there are areas that we could improve on and will continue to strive to provide the highest quality service for our patients.

CQC Rated Dysart Surgery as OUTSTANDING! see the report here