Crown Street Surgery

We carried out an announced inspection at Crown Street Surgery between 16 and 19 May 2022. Overall, the practice is rated as requires improvement with the following key question ratings:

• Safe – requires improvement
• Effective – requires improvement
• Caring - good
• Responsive - good
• Well-led – requires improvement

Why we carried out this inspection

This inspection was a comprehensive inspection, and was our first inspection of this location since their updated registration with CQC. We have previously inspected this location under a previous registration.

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 using video conferencing
• 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
• Reviewing patient feedback
• Circulating an electronic staff questionnaire.

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 Requires Improvement overall.

We found that:

• Staff treated patients with kindness and compassion. Staff helped patients to be involved in decisions about care and treatment and respected patients’ privacy and dignity.
• The practice organised and delivered services to meet patients’ needs, and people were able to access care and treatment in a timely way.
• The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
• The practice’s systems for the appropriate and safe use of medicines were not always effective.
• The practice was not always able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• There was limited monitoring of the outcomes of care and treatment, and there was not always appropriate oversight of the management of patients with long-term conditions.

We found one area of outstanding practice:

• The practice took a holistic and patient-centred approach when developing and reviewing patient individual care plans, which included care plans for patients living with dementia or learning disabilities. Care plans evidenced that staff completed a comprehensive review of each patient’s care and treatment needs, with documented input and discussion from patients, their relatives and/or their carers. Key information was proactively shared with other healthcare services, such as out of hours GP services, to ensure continuity of care for patients.

We found one breach of regulations. The provider must:

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

Although not a breach of regulations, the provider should:

• Improve the uptake of cervical cancer screening.
• Develop a programme of quality improvement and clinical audit that is aimed at improving the quality of patient care.
• Develop a vision, values and a strategy for the practice’s future ambitions.
• Improve processes to record and share any learnings identified from complaints.
• Improve infection prevention and control audits to ensure all concerns are identified and addressed.

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