The Care Quality Commission
  • Doctor
  • GP practice

White Rose Surgery

Overall: Good read more about inspection ratings

Exchange Street, South Elmsall, Pontefract, West Yorkshire, WF9 2RD (01977) 642412

Provided and run by:
White Rose Surgery

All Inspections

20 October 2022

During a routine inspection

We carried out an announced comprehensive inspection at White Rose Surgery on 19 and 20 October 2022. Overall, the practice is rated as good, and as follows for the key questions:

Safe – good

Effective - good

Caring - good

Responsive - outstanding

Well-led - good

At the previous inspection in September 2015 the practice was rated as outstanding overall, with individual ratings of outstanding for providing effective and responsive services.

At this inspection, the practice has been rated as good for the provision of effective services and and outstanding for the provision of responsive services. Effective is rated as good because since the 2015 inspection some elements recognised as outstanding have been mainstreamed into general practice nationally. Whilst the provider had maintained this good practise, the threshold to achieve an outstanding rating had not been reached for this key question.

We have rated responsive as outstanding due to the provision of a dedicated community long-term conditions nurse led service who dealt with the care of housebound patients, the delivery of enhanced screening for certain long-term conditions prevalent in the community, and high patient satisfaction levels in relation to services provided.

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

Why we carried out this inspection

We carried out this comprehensive inspection in line with our inspection priorities, due to the length of time since the last inspection.

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 some staff interviews using video/telephone 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 site visit to location.
  • Reviewing completed staff questionnaires.
  • Speaking with a patient and reviewing their feedback.

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 found that:

  • 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.
  • There were systems in place to safeguard children and vulnerable adults from abuse. Staff we spoke with knew how to identify and report safeguarding concerns.
  • There was a programme of quality improvement, this included clinical audit and monitoring prescribing performance.
  • The practice supported staff development, and was an accredited training practice for GP trainees.
  • Staff informed us that they had access to policies, procedures and guidance relevant to their role and responsibilities, this included clinical protocols and guidance.
  • The provider had appropriate clinical equipment in place to enable the effective assessment of patients. The provider also had the necessary equipment and medicines available to deal with medical emergencies including emergency resuscitation equipment.
  • The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care. Business planning had been undertaken and we saw that progress against this was monitored.
  • The management team in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
  • The practice hosted several staff from their Primary Care Network (PCN) who delivered services at the location and at other locations operated by the provider.

We saw an area of outstanding practice:

  • The practice had developed a community long-term conditions service for housebound patients, staffed by a specialist nurse. We saw evidence which indicated that this, and the advanced care practitioner led acute home visiting service, had contributed to reduced attendances at local urgent and emergency care services.

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

  • Make improvements to increase the uptake of cervical screening.
  • Formalise clinical supervision practices for non-medical prescribers.
  • Follow best practice guidance in the management and monitoring of people on high risk medicines, and those with long-term conditions.
  • Establish the vaccination status of staff working in the practice in line with current guidance.
  • Establish a patient participation group to improve patient engagement and feedback routes.

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

2 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at White Rose Surgery on 2 September 2015. Overall the practice is rated as outstanding.

We specifically found the practice to be outstanding for providing effective services to older people and people with long term conditions. Also outstanding for providing responsive services to older people, people with long term conditions and people whose circumstances may make them vulnerable

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

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.
  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents, near misses and any identified safeguarding issues. There was a clear leadership structure and staff felt supported.
  • Risks to patients were assessed and well managed.
  • The practice had good facilities and was well equipped to treat and meet the needs of patients.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were available for patients the same day as requested, although not necessarily with a GP of their choice.
  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
  • The practice sought patient views how improvements could be made to the service, through the use of patient surveys, friend and family test and the patient participation group.

We saw several areas of outstanding practice:

  • The practice routinely screened for chronic obstructive pulmonary disease (COPD) in all patients who were smokers and aged 40 and above; irrespective of any apparent symptoms. This had resulted in a higher than average prevalence of COPD for the practice. As a result of these interventions the practice could evidence a 26% reduction in COPD hospital admissions in the previous 12 months.
  • The practice had an in-house smoking cessation service which was facilitated by a trained member of staff. Through interventions and support offered they could evidence the number of patients who had stopped smoking during the previous 12 months. This had resulted in a 16% reduction of registered smokers.
  • The practice had employed a nurse who specifically focused on house bound patients who either had a long term condition or were elderly. Through targeted interventions, this had resulted in an overall reduction of unplanned hospital admissions in the previous 12 months, 30% of which were patients who were over the age of 80.
  • There was a fully equipped gym located in the practice, with qualified gym instructors to assist patients in improving their mobility, managing body weight and maintaining a healthy lifestyle. This was available to all patients who were registered with the practice.
  • The practice leaflet and other health care advice/information had been translated into Polish to support the 10% of registered patients who were Polish speaking

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice