Background to this inspection
Updated
27 May 2021
All Saints surgery is registered with CQC as a GP partnership provider and is located in the town of Burton on Trent. The practice provides GP services to approximately 10163 patients under the terms of a General Medical services contract with NHS England. A GMS contract is a contract between NHS England and general practises for delivering General Medical services.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is a member of the NHS East Staffordshire Clinical Commissioning Group (CCG). According to the practice records, the ethnicity of patients registered at the practice are approximately 42% Pakistani/ Bangladeshi origin and 30% white mixed race British, 16% Eastern European. 6.4% Arabic and the remaining are identified as Chinese and other Asian groups as well as travellers.
The practice area has a higher level of deprivation being in the third most deprived decile which may mean that there is an increased demand on the service provided. The practice population age distribution is broadly in line with local and national averages.
The practice provides a number of clinics such as long term condition management including asthma, diabetes and blood pressure management.
The level of income deprivation affecting children is 22% which is slightly higher than the national average of 20%. The level of income deprivation affecting older people is 25% compared to the national average of 20%.
The Practice is a purpose-built premises, The building is single storey and owned by the partners. There is a small car park.
Practice staffing comprises:
Two male GP partners who provide the equivalent of two whole time.
One sessional GP who will join the partnership in the future, providing six sessions.
One long term locum GP (on maternity leave and who will return part time).
One Clinical Pharmacist who provides six sessions over three full days. The practice is in the process of appointing an additional part time clinical pharmacist for three sessions per week.
A non-clinical partner practice manager.
One operations manager.
Two female practice nurses; both full time.
One female phlebotomist/health care assistant. Part time two full days.
The practice has recently recruited a second phlebotomist who will work four morning sessions.
A team of four reception staff and administrators who are all full time.
One nurse may retire in the near future and a full-time nurse post is currently being advertised externally.
The practice has also identified a Primary Care physician vacancy which they have advertised.
There is a vacancy for a nurse associate: the advert and programme will be run by the PCN and has a two-year training programme.
The practice is open from 8am to 6pm Monday to Friday and from 8am to 12:30pm on Saturdays. The practice has opted out of providing an out of hours service. When the practice is closed, the out of hours service provider is Staffordshire doctors urgent care limited (SDUC). Patients may also call NHS 111 or 999 for life threatening emergencies.
Routine appointments can be booked in person by telephone or online. Home visits are available to patients with complex needs or who are unable to attend the surgery. Surgery consulting times with the GP are available from 8:30am to 12pm and 3:30pm to 6:30pm on weekdays and 8am to 12 midday on Saturdays. The nearest walk in centre is based at London Road Community Hospital.
Further details about the practice can be found by accessing the practice’s website at www.allsaintssurgery.co.uk.
Updated
27 May 2021
We carried out an announced inspection at All Saints Surgery on 29 April 2021. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 12 July 2019, the practice was rated Requires Improvement overall, and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for All Saints Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection to follow up on:
- Breaches in Regulations relating to safe care and treatment and good governance.
- Four best practice recommendations, which were:
- Improve the identification of carers, including electronic coding systems to enable this group of patients to access the care and support they need.
- Develop, seek and gather patient views.
- Implement strategies to improve the uptake for cervical screening and the cancer screening programmes.
- Implement strategies to improve the uptake of childhood immunisations for children under one year old.
How we carried out the inspection/review
Throughout the Covid 19 pandemic, CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall and good for all population groups except Families, children and young people, and Working age people (including those recently retired and students) which we have rated as requires improvement in responsive.
This is because the practice has not met any of the five-childhood immunisation minimum targets; and that the uptake for cervical screening and the cancer screening programmes require further improvement.
We found that:
- The practice had met the requirement notices we set in response to the breaches in regulation we found at the July 2019 inspection.
- The practice had improved its processes to monitor patients on medicines to reduce the risk of blood clots and could demonstrate reviewing blood monitoring tests before these medicines were prescribed.
- Patients on a specific medicine for blood pressure management received blood tests and these tests were reviewed prior to medicines being prescribed.
- The practice had developed a system to prevent the duplication of prescriptions issued.
- The practice had electronically coded patients notes for the out of hours service.
- There was clear electronic coding for all family members when a safeguarding issue was identified.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Continue to Implement strategies to improve the uptake for cervical screening and the cancer screening programmes.
- Further improve uptake of childhood immunisations for all children between 1 and 5 years old.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care