Witton Street Surgery

Updated 19 July 2022

Witton Street Surgery is located in the Northwich area of Cheshire at:

162 Witton Street

Northwich

Cheshire

CW9 5QU.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, surgical procedures and treatment of disease, disorder or injury.

The practice is situated within the Cheshire West and Chester Commissioning Group (CCG) and delivers General Medical Services (GMS)to a patient population of approximately 8,624. This is part of a contract held with NHS England.

Information published by Public Health England shows that deprivation within the practice population group is in the sixth lowest decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 97.5% White, 1.2% Asian, 0.2% Black, 0.9% Mixed, and 0.1% Other.

There are a higher number of older people registered at the practice compared to the national average and a lower number of working age people registered.

There are four GP partners at the practice along with three other GPs and a trainee doctor. There are two practice nurses, a clinical pharmacist and a musculoskeletal physiotherapist at the practice. A healthcare assistant supports the nursing team. The team are supported at the practice by a team of reception/administration staff. A central management team comprising of a practice manager, human resources manager and operations manager oversee the running of the practice and are based at the location. Dr Karen Glenton is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, the practice offered telephone consultations, but had started to offer more face to face appointments following feedback from patients.

The out of hours services are provided by Open for you.

Updated 19 July 2022

We carried out an announced inspection at Witton Street Surgery on 18 May 2022. Overall the practice is rated as good.

Safe – requires improvement

Effective – good

Caring- good (rating carried forward from previous inspection)

Responsive- good (rating carried forward from previous inspection)

Well-led – good

Why we carried out this inspection

This inspection was a focused inspection covering safe, effective and well-led key questions. At the last inspection on 29 January 2020, the practice was rated as good overall with the key questions safe, effective and well-led being rated good. We carried out this inspection following information of concern being received by the Commission.

How we carried out the inspection

Throughout the 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
• 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.

We rated the practice as requires improvement for providing safe services. This is because:

• Not every patient prescribed a medicine that required monitoring had a review undertaken within the last twelve months.
• Separate records were kept relating to monitoring patients prescribed high risk medicines and the information contained within was not always available in the patient records.

We rated the practice as good for providing effective services. This is because patients received coordinated and person-centred care and were guided in improving their health. Staff were supported in their roles and responsibilities.

We rated the practice as good for providing well-led services. This is because leaders demonstrated that they understood the challenges to quality and sustainability and had identified actions to address challenges. Staff felt well supported and the service used feedback from staff and patients to make improvements.

The provider must:

• Ensure care and treatment must be provided in a safe way for service users.

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

• Continue to review DNACPR records on a regular basis.
• Continue to work to improve the uptake of cancer screening and childhood immunisations.

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