The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Surgery York Road

Overall: Good read more about inspection ratings

York Road, Rotherham, S65 1PW (01709) 836290

Provided and run by:
York Road Surgery

Important: The provider of this service changed. See new profile
Important: The provider of this service changed. See old profile

All Inspections

11/06/2021

During an inspection looking at part of the service

We carried out an announced remote inspection of The Surgery York Road on 11 June 2021.

During our last comprehensive inspection of the practice in November 2018 (when it was registered with CQC as Dr Naranammalpuram Srinivasan), the practice was rated as good overall but as requiring improvement for the provision of effective services. During a subsequent follow-up inspection in July 2020, it was rated as good overall and for the effective key question.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on concerns we received about the practice.

How we carried out the inspection/review

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 remotely. This was with consent from the provider and in line with all data protection and information governance requirements. We focused our assessment on the safe and well-led key lines of enquiry.

This included:

  • Conducting staff interviews using video conferencing
  • Requesting evidence from the provider
  • Sending electronic staff questionnaires to all staff employed at the practice

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 did not rate this practice following this inspection.

We found that:

  • There were adequate systems to assess, monitor and manage risks to patient safety.
  • There was compassionate, inclusive and effective leadership at all levels.
  • The practice had a culture which drove high quality sustainable care.
  • The practice had systems in place to continue to deliver services, respond to risk and meet patients’ needs during the pandemic.
  • The provider's registration with the Commission was not correct and did not reflect recent changes to their partnership.

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

  • Review their whistleblowing and speaking up policy to ensure it contains accurate and up-to-date contact details, and includes details for the practice's nominated Freedom to Speak Up Guardian.

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

6 July 2020

During an inspection looking at part of the service

We carried out a desk top follow up inspection at The Surgery York Road on 6 July 2020. This inspection was to follow up a previous inspection of  Dr Naranammalpuram Srinivasan,  in November 2018.  During that inspection a new provider was registering with the Commission to take the service over. 

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

  • The practice’s performance on quality indicators for some long-term conditions and cancer indicators for working age people was significantly below local and national averages. Although some progress had been made there was limited improvement seen at the time of inspection.

At this inspection, we found that the new provider had satisfactorily addressed most of these areas.

We based our judgement of the quality of care at this service on a combination of:

  • Documentation and information from the new provider and information from our ongoing monitoring of data about services.

We have rated this practice as good for being effective and good overall and for all population groups apart from working age people which is rated as requires improvement.

We rated the practice good for providing effective services because:

  • The practice's performance on quality indicators for those with some long-term conditions had improved and were mostly  in line with local and national averages. 
  • ​However, performance data for cervical cancer screening was significantly below local and national averages. The practice remains requires improvement for the working age people population group.

In addition, the new provider shared with us the actions they had taken as a result of the areas we told them they should improve in the November 2018 inspection report.

  • Risk assessments had been completed relating to blind cords, hot water and emergency medicines.  As a result blind cords had been secured to the wall with cleats. Water temperature checks had been completed and hot water warning signs installed. Emergency medicines were checked weekly.
  • An infection prevention and control (IPC) action plan had been developed from the August 2019 IPC audit. Actions had been completed in accord with the findings.
  • An up to date record of staff immunisation status was now kept.
  • Staff routinely asked patients during consultations whether they had a caring responsibility and would offer support accordingly. A notice board in the waiting area was designated to provide local information and support groups for carers. There were 43 patients registered at the practice with caring responsibilities which represents 1% of the practice population.
  • The number of pre-bookable and same day appointments was increased by employing two advanced nurse practitioners and three GP locums.  Extended hours appointments were available on Tuesday evenings until 7.45pm.

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

  • Continue to review the uptake of cervical cancer screening with a view to improving achievement.

​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