Castle Street Surgery

This inspection was an announced comprehensive inspection carried out on 26 November 2019 to confirm that the practice had carried out the required improvements that we identified during our previous inspection on 21 November 2018. Overall the practice remains rated as requires improvement.

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 requires improvement overall and requires improvement for all population groups.

We rated the practice as good for providing safe services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There were records in place of the vaccination status of staff.
• Improvements had been made to the systems to manage IPC and actions had been taken in response to IPC audits.
• Risk assessments were in place to determine which emergency medicines they needed to stock on the premises.
• The safeguarding policies were overdue a review. Up to date information regarding the local authority contacts was available in the consultation and treatment rooms.
• We found two members of the reception team did not have a Disclosure and Barring Service (DBS) check. There was no risk assessment in place to determine whether a DBS check was required for these staff.

We rated the practice as good for providing effective services with requires improvement for working age people because:

• The uptake rate for cervical screening was below the 80% NHS England target.
• Recommended training and appraisals had been completed for all staff.
• Clinical audits were undertaken to demonstrate quality improvement.
• Performance data showed the practice was comparable with others both locally and nationally.

We rated the practice as requires improvement for providing caring services because:

• The practice was rated lower than others both locally and nationally for some areas of the National GP Patient Survey relating to their experiences during consultations.
• The practice had identified less than 1% of the practice population as carers.

We rated the practice as requires improvement for providing responsive services because:

• The practice was rated lower than others both locally and nationally for some areas of the National GP Patient Survey relating to access to the practice and appointment booking.
• The practice had made changes to the telephone system to improve patient satisfaction when they accessed the practice.

We rated the practice as good for providing well led services because:

• Improvements had been made to the oversight of staffing needs, training and appraisals. All staff training and appraisals were up to date.
• Staff informed us they felt supported by the management team.
• Business continuity plans were in place and used to maintain services when the practice experienced major floods to their main site.

Whilst we found no breaches of regulations, the provider should:

• Carry out a review of the safeguarding policies so staff are assured that the information they contain is current.
• Complete a risk assessment to determine whether a DBS check is required for staff who do not have one.
• Improve the identification of carers to enable this group of patients to access the care and support they need.
• Continue to encourage patients to participate in cancer screening programmes.
• Continue to monitor patient feedback and take appropriate actions to improve patient satisfaction.

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