The Care Quality Commission
  • Doctor
  • GP practice

Park Street Surgery

Overall: Good read more about inspection ratings

Park Street, Bootle, Merseyside, L20 3DF (0151) 922 3577

Provided and run by:
Park Street Surgery

All Inspections

15 November 2022

During an inspection looking at part of the service

We carried out a short notice announced inspection at Park Street Surgery on 15 November 2022.

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

Why we carried out this inspection

This was a focused inspection following receipt of information of concern having been received by the Care Quality Commission.

We looked at specific information in the following key question:

• Safe

How we carried out the inspection.

This unannounced inspection was carried out on site by a team of two inspectors.

The inspection included

  • Conducting staff interviews
  • Reviewing patient records to identify issues and clarify actions taken by the provider.

Requesting evidence to be submitted by the provider.

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:

  • There were no backlogs of work and staff kept up to date with managing correspondence.
  • Reviews for patients with long term conditions were up to date for the sample of patients we looked at.
  • High risk medicines were only prescribed following appropriate checks for the sample of patients whose records we looked at.
  • Staffing rotas showed that a regular clinical staff team was in place and this was being increased with the appointment of additional GPs.
  • The provider had systems in place for monitoring and governing the service. These were not always clearly detailed to staff.

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

  • Review staffing levels across the non-clinical staff team to ensure staff are able to meet their roles and responsibilities.
  • Support staff through changes to their roles and responsibilities and ensure they are clear on these. Improve the communication between the leadership team and staff at the practice.
  • Share details of the governance systems in place to support the safe running of the practice and share the outcome of the monitoring that is taking place at provider level.

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

16 July 2021

During an inspection looking at part of the service

We carried out an announced inspection at Park Street Surgery on 16 July 2021. Overall, the practice is rated as ‘Good’.

The ratings for each key question

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 12 November 2019 the practice was rated as Requires Improvement for providing safe and well-led services and overall.

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

Why we carried out this inspection

This inspection was a focused inspection that included a site visit to follow up on breaches of regulations identified at the previous inspection. We carried over the ratings of Good for the key questions of caring and responsive from the previous inspection.

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.

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 and for all population groups.

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.
  • The way the practice was led and managed promoted the delivery of good quality, person-centre care.

The provider had taken action to meet the requirement notices we served following the last inspection. These actions included: ensuring closer monitoring of patients prescribed higher risk medicines, improvements to the checks for the storage of emergency medicines and vaccines and increased security of treatment rooms. Systems for governing the practice had also been improved with staff having been provided with training in using the provider’s IT system for reporting incidents and complaints.

Since the last inspection the provider has developed a programme of two cycle clinical audits to demonstrate improvements in care and treatment for patients. This was in line with our recommendation.

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

  • Review the system of checks and searches used within the clinical record system to improve outcomes for patients.
  • Review current recruitment procedures so that all required recruitment checks are completed prior to employing staff.
  • Review the reporting of significant events to ensure all incidents and events are captured and acted upon.
  • Formalise the review of consultations and prescribing for non-medical prescribers.
  • Review how checks on emergency medicines and equipment are recorded.

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

12 November 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Park Street Surgery on 12 November 2019 due to the length of time since the last comprehensive inspection.

Following our Annual Regulatory Review of the information available to us, including information provided by the practice, we planned to focus our inspection on the following key questions: Effective and Well-led. During the inspection we included the safe key question as a result of our findings on the day.

From the Annual Regulatory Review we carried forward the ratings from the last comprehensive inspection for the following key questions: Caring and Responsive.

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 and good for all population groups.

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

  • Systems in place for ensuring safe practice were not always well established.

We rated the practice as requires improvement for providing well-led services because:

  • The practice was in a period of transition and governance systems had not been clearly established. The provider did not have sufficient leadership oversight in some areas as a result.

We rated the practice as good for providing effective, caring and responsive services because:

  • 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.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements:

  • Ensure systems are in place to safeguard patients from avoidable risks.
  • Establish effective processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report)

The areas where the provider should make improvements:

  • Develop the current programme of audits to include two cycle clinical audits that demonstrate improvements in care and treatment for patients.

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 May 2016

During a routine inspection

We carried out an announced comprehensive inspection at this practice on the 18th November 2014 and at this time the practice was rated as good.

However, breaches of a legal requirement were also found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On the 6 May 2016 we carried out a focused review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This review was carried out to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in November 2014.

This report covers our findings in relation to those requirements and areas considered for improvement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Park Street Surgery on our website at www.cqc.org.uk.

The findings of this review were as follows:

  • The practice had addressed the issues identified during the previous inspection.

  • Appropriate recruitment checks had been carried out for staff. The practice had undertaken checks for all staff members.

  • The practices complaints policy had been updated in line with recognised guidance and contractual obligations.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Park Street Surgery. The practice is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on 18 November 2014 at the practice location in Park Street, Bootle. We spoke with patients, relatives, staff and the practice manager.

The practice was rated as Good. They provided effective, responsive, caring and compassionate care that was well led and addressed the needs of the diverse population it served.

Our key findings were as follows:

  • The practice had a good track record for maintaining patient safety. Effective systems were in place to ensure patients were safe from risks and harm. Incidents and significant events were identified, investigated and reported. Lessons learnt were disseminated to staff. However improvements were required to ensure staff were safely recruited and required information was held in relation to staff.
  • Patients spoke highly of the practice. They were very pleased with the individualised care given by all staff and they told us staff were kind, compassionate and caring.
  • The practice served a diverse population in a deprived area of Liverpool. The practice provided good care to its population taking into account their health and socio economic needs. Patients were listened to and feedback was acted upon. Complaints were managed appropriately.
  • Patient’s needs were assessed and care was planned and delivered in line with current legislation and guidance.
  • The practice continued to monitor, evaluate and improve services. They worked in collaboration with the CCG and NHS England. Staff enjoyed working for the practice and felt well supported and valued.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure full and complete required information relating to workers is obtained and held when recruiting staff. The practice should ensure its recruitment arrangements are in line with Regulation 21 and Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff. This must include a Disclosure and Barring Service (DBS) check for all staff with chaperoning responsibilities.

In addition the provider should:

  • Ensure all audits follow a consistent format and are shared and disseminated across all staff. The audit cycle should be fully completed in order to demonstrate actions taken have enhanced care and improvements have been made.
  • Ensure all staff who undertake chaperone duties are trained and competent to do so.
  • Ensure the complaints policy was reviewed and in line with recognised guidance and contractual obligations for GPs in England. There should be an up to date information leaflet advising patients of how to complain and other bodies they can go to when their complaint is not resolved

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice