• Doctor
  • GP practice

Witton Street Surgery

Overall: Good read more about inspection ratings

162 Witton Street, Northwich, Cheshire, CW9 5QU (01606) 544850

Provided and run by:
Witton Street Surgery

All Inspections

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

29/01/2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Witton Street Surgery on 29 January 2020. We carried out an inspection of this service to follow up on a breach of regulations made at the comprehensive inspection on 19 March 2019 where the service was rated Good overall but Requires improvement for providing safe services. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Safe
  • Effective
  • Well Led

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 action had been taken to address the breaches identified at the last inspection on 19 March 2019 and we have rated this practice as Good overall and Good for all population groups.

We rated the practice as Good for providing safe, effective and well-led services because:

  • There were systems in place to promote safe working practices and the safety of patients.
  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
  • Staff worked together and with other organisations to deliver effective care and treatment.
  • There was good communication between staff and staff told us they felt well supported.

  • The practice sought the views of patients and staff and acted on them.
  • There was a focus on continuous improvement.

The areas where the provider should make improvements:

  • Continue with audits to monitor whether staff have received relevant immunisations appropriate for their role.

  • Fire marshal training to be provided to staff with this responsibility.
  • The significant event record to record when actions have been completed.
  • The results of patient blood tests that have been accessed through the records held by the anticoagulant clinic to be consistently recorded in patients records. This should be audited to ensure the revised policy is followed.
  • A record listing each safety alert and the action taken would make it easier to review this information.

  • Steps should be taken to prevent the plugs to the vaccine fridges being accidentally disconnected from the power supply.
  • A more planned approach to quality improvement should be put in place.
  • Provide formal training to non-clinical staff in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).
  • Continue to encourage patients to join the patient participation group.

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

19/03/2019

During a routine inspection

We carried out an announced comprehensive inspection at Witton Street Surgery on 19 March 2019 as part of our inspection programme.

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 have rated this practice as good all population groups.

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

  • The systems for monitoring medicines needed to be more robust.

We rated the practice as good for providing effective, caring, responsive and well-led services.

We found that:

  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff were provided with the training and support required for their roles.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice monitored patient access to services. They adjusted access to ensure that it met the needs of patients.
  • The practice organised and delivered services to meet the needs of patients.
  • There was a system in place for investigating and responding to patient feedback including complaints.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The area where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Provide guidance to all staff on the updated safeguarding policies and procedures.
  • Monitor the system to record spot checks of the cleaning undertaken by the cleaners and to record when equipment and clinical areas are cleaned.
  • Record all significant events on one record to enable patterns and trends and progress to be more easily identified.
  • Review the system to monitor safety alerts.
  • Introduce a comprehensive programme of quality improvement and use this information about care and treatment to make improvements.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

25 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Witton Street Surgery. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring, safe and responsive services. It was also good for providing services to meet the needs of all population groups of patients.

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

  • There were systems in place to protect patients from avoidable harm and abuse. Staff were aware of procedures for safeguarding patients from risk of abuse. There were appropriate systems in place to protect patients from the risks associated with medicines. The staffing numbers and skill mix were reviewed to ensure that patients were safe and their care and treatment needs were met. We found improvements should be made to the records for staff recruitment.
  • Patients care needs were assessed and care and treatment was being considered in line with best practice national guidelines. Staff were proactive in promoting good health and referrals were made to other agencies to ensure patients received the treatments they needed. We found improvements should be made to the records of staff training.
  • Feedback from patients showed they were happy overall with the care given by all staff. They felt listened to, treated with dignity and respect and involved in decision making around their care and treatment.
  • The practice planned its services to meet the differing needs of patients. The practice encouraged patients to give their views about the services offered and made changes as a consequence.
  • Quality and performance were monitored, risks were identified and managed. The practice ensured that staff had access to learning and improvement opportunities.

We saw an area of outstanding practice:

  • The practice was aware of patients in vulnerable circumstances and ensured they had appropriate access to health care to meet their needs. For example, one of the GPs was the Clinical Commissioning Group (CCG) lead for the IRIS programme (a general practice-based domestic violence and abuse (DVA) training support and referral programme). The GP lead was also involved in the training and raising awareness with all practices within the CCG area. Involvement in this programme had resulted in the practice identifying more patients at risk of domestic violence. The CCG had also identified the practice as being a high referrer for patients to gain support from other agencies to improve their health, safety and wellbeing. Reception staff were aware of the practice’s involvement in this programme and ensured any patients who appeared to be distressed or injured were seen by a GP immediately. The GP lead for the programme ensured all clinicians had access to information leaflets to share with patients during consultations. The practice also supported partner agencies to access the practice to ensure vulnerable patients were seen in a safe environment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice