All inspections: Station Drive Surgery - Care Quality Commission

We carried out a review of the data available to us about Station Drive Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Station Drive Surgery, you can give feedback on this service.

We carried out an announced comprehensive at Station Drive Surgery on 26/09/2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - outstanding

Well-led - good

Following our previous inspection on 19 July 2016 the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Station Drive Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

Conducting staff interviews using video conferencing.
Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
Reviewing patient records to identify issues and clarify actions taken by the provider.
Requesting evidence from the provider.
A site visit to surgery
Staff feedback questionnaires.

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 found that:

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. Patient and stakeholder feedback was very positive about the care received.
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.

We rated the practice as outstanding for providing a responsive service because:

The practice had responded to the needs of its population by delivering services differently during the pandemic. For example, one GP undertook three visits to Ludlow Community Hospital every day between 8am and 10pm, seven days a week to ensure they could remain open with both covid positive and covid negative patients. Station Drive Surgery led the vaccination scheme and continued to offer weekly walk-in clinics.
They had worked closely with the immigrant population and the traveller community and worked towards tackling inequalities through various working partnerships.
The practice demonstrated high commitment to the needs of the local community. The offered free pop-up screening, regular attendance to the local breastfeeding group and was also involved with the “Hands Together Ludlow’s Mentoring Scheme”, working to provide role models, peer support and improved employment prospects for young people.
GP’s were involved with community first aid and CPR courses aimed at parents, carers and grandparents and carried out educational sessions in the community, covering aspects such as home emergency care including sepsis and meningitis.
Patients were very positive about access to appointments at the practice. All four indicators from the national GP survey were above the local and national averages with 89.5% of respondents stating they were satisfied with the appointment offered. Eighty four percent responded positively to the overall experience of making an appointment.

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

Ensure eligible patients receive a structured medicines review.
The escalation route for patients to follow, should they not be happy with the outcome of the investigation into their complaint, should be shared in the complaint response letters.
Review and monitor historical medicines alerts to ensure compliance.
Ensure staff records include details of immunisation.
Review staff training records to ensure all staff have received the appropriate training.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Station Drive Surgery on 19 July 2016. Overall the practice is rated as good.

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

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice had instigated and shared Medical Advice Forms, now used across the Clinical Commissioning Group (CCG) to help improve efficiency and speed of advice.

Feedback from patients about their care was consistently positive.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example, patients could directly access physiotherapy and self-refer without GP authorisation. A Physiotherapy assessment service offered 15-minute physiotherapy assessment appointments bookable via the practice reception team every Thursday morning at the practice.

The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, they had improved opening times, conducted a patient waiting time audit, and completed surveys of extended access available at the practice since August 2015. They also completed building improvements with the PPG involved in the design, which was completed in 2016.
The practice had good facilities and was well equipped to treat patients and meet their needs.
The practice had a clear vision, which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
The practice had strong and visible clinical and managerial leadership and governance arrangements.

However there were areas of practice where the provider should make improvements:

Improve the documentation of actions taken following any risk assessments.
Consider a system to support patients who may be hearing impaired in the absence of a hearing loop.
Improve the visibility of information on the availability of interpreter services within the waiting room.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Station Drive Surgery

All Inspections

6 July 2023

During a monthly review of our data

26/09/2022

During a routine inspection

19 July 2016