We carried out an announced comprehensive inspection at York Road Surgery on 6 and 7 December 2022. Overall, the practice is rated as good.
- Safe - requires improvement
- Effective - good
- Caring - good
- Responsive - good
- Well-led - good
Why we carried out this inspection
This was our first inspection of the practice since their new registration with CQC in November 2021.
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.
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.
- 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-centre care.
We found the following areas of outstanding practice:
- The practice was responsive to patient demand and quickly adjusted its services to ensure patients could access services when they needed to. We saw examples of where the practice had worked to put on additional GP sessions for later the same day where high demand was seen. We saw the practice maintained excellent appointment availability across all clinical roles, with routine appointments generally available within 24 hours of a request.
- The practice took a proactive approach to the management of patients with long term conditions, in particular with asthma. We saw staff placed patients at the centre of their care and took the time to fully understand their care needs and requirements. Staff helped to educate patients on their condition and took the time to ensure patients were confident in using all medicines and equipment prescribed to them, such as inhalers. By undertaking a thorough and effective asthma review, staff explained how they aimed to reduce the frequency in which patients required rescue steroids or further treatment.
- Staff had created a number of practice-specific minor treatment policies, which were linked to the Clinical Knowledge Summaries (CKS) issued by the National Institute for Health and Care Excellence (NICE). Examples included minor treatment policies for the management of fever and epistaxis.
Whilst we found no breaches of regulations, the provider should:
- Improve recruitment systems to ensure all staff have received all vaccinations and immunisations as appropriate for their role, and training completed by locum GPs is recorded effectively.
- Improve the quality of medication reviews to ensure reviews cover all prescribed medicines, including any monitoring requirements of high risk medicines.
- Improve medicine management systems to ensure emergency medicines are stored in line with recommendations, records of blank prescriptions are accurate, and historic safety alerts are routinely reviewed.
- Implement a system of formalised and regular clinical supervision for all non-medical prescribers.
- Improve the uptake rates of childhood immunisation and cervical cancer screening.
- Implement a formal clinical audit programme, with second cycle audits undertaken to check for any required improvements.
- Develop a practice vision, in collaboration with feedback from staff and patients, that is supported by a credible strategy.
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