We carried out a review of the data available to us about High Street Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about High Street Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at High Street Surgery on 5 October 2016. The overall rating for the practice was good with requires improvement for safety. The full comprehensive report on the 5 October 2016 inspection can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 17 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 5 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as Good.
Our key findings were as follows:
Improvements had been made to the way significant events incidents were recorded, investigated and reviewed to ensure opportunities for learning were maximised.
Actions taken in response to safety alerts had been recorded.
Safety notices to identify the storage area for liquid nitrogen had been displayed.
A risk assessment for the provision of emergency drugs at both sites had been completed.
Systems had been improved to assist the provider to identify defects and stock issues related to emergency equipment.
Staff had completed infection prevention and control training.
The practice had also made the following improvements:
Information about duty of candour requirements had been provided and staff were knowledgeable about these requirement’s.
The recruitment procedure had been further developed to include how training would be verified and gaps in employment history would be identified and managed.
Arrangements for cleaning of carpets had been improved and we found the carpets in a clean condition.
An action plan to address poor patient satisfaction with telephone access to the practice had been developed and implemented. The telephone system had been improved following an analysis of use with the telephony provider. The telephone system also allowed the practice to monitor calls and waiting times. Systems to enable the practice to text patients and for patients to be able to cancel appointments by text had also been implemented. The practice was also promoting booking on line and had provided information for patients relating to this. Pre-bookable telephone consultations had been implemented and additional, telephone on the day, access to speak to a GP was available 11.30am to 12 midday. Patient satisfaction had been reviewed by the practice and results showed improvement in patient experience and patients we spoke with were satisfied with access to appointments.
Access arrangements to the main site for patients with a disability had been improved. A doorbell with a sign for patients had been installed so staff could be made aware if patients required help with the doors.
The complaints information was displayed at the branch site.
However, there were also areas of practice where the provider should make improvements.
Review processes to ensure all staff understand their role in monitoring and maintaining the cold chain for vaccines stored in the practice.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at High Street Surgery on 5 October 2016. Overall the practice is rated as Good.
Our key findings across all the areas we inspected were as follows:
There was a system in place for reporting and recording significant events and some lessons were shared to make sure action was taken to improve safety in the practice. However, not all incidents were appropriately recorded and there was a lack of clarity and consistency in this area so opportunities for learning and improvement were not maximised.
Although the majority of risks to patients who used services were assessed patient’s health and welfare may be compromised due to limited provision of emergency drugs and shortfalls in checks of emergency equipment.
The practice had processes in place to keep patients safeguarded from abuse.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Information about services and how to complain was easy to understand although information about the complaints process was not available or displayed at the branch site. Improvements were made to the quality of care as a result of complaints and concerns.
Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
The practice had good facilities and was equipped to treat patients and meet their needs. However, access to the practice at the main site may be compromised for some patients due to a heavy front door.
There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on. The practice had experienced a number of challenges in recent months but had implemented plans to meet these and improve. Patients told us they felt the practice had improved. When we advised the management team of our findings, where possible, they took immediate action to address these.
The provider complied with the requirements of the duty of candour although there was a lack of understanding in the management team about the term duty of candour.
The areas where the provider must make improvement are:
Ensure staff understand how to identify and record incidents appropriately so opportunities for learning and improvement are maximised.
Evidence the actions taken in response to safety alerts.
Provide safety notices to identify the storage area for liquid nitrogen.
Risk assess the provision of emergency drugs at both sites.
Implement processes to ensure defects and stock issues related to emergency equipment will be identified and managed in a timely manner.
Ensure all staff complete infection prevention and control training.
The areas where the provider should make improvement are:
Further develop the recruitment procedure to include checks of training and the identification of gaps in employment history and processes to manage this.
Review access arrangements to the main site for patients with a disability.
Review arrangements for cleaning of carpets and ensure carpets are maintained in a clean condition.
Develop an action plan to address poor patient satisfaction with telephone access to the practice.
Provide complaints information at the branch site.
Provide information for staff about duty of candour requirements.
Chief Inspector of General Practice