18 May 2022, 19 May 2022
During an inspection looking at part of the service
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