• Doctor
  • GP practice

Sheet Street Surgery

Overall: Requires improvement read more about inspection ratings

The Surgery, 21 Sheet Street, Windsor, Berkshire, SL4 1BZ (01753) 860334

Provided and run by:
Sheet Street Surgery

Latest inspection summary

On this page

Background to this inspection

Updated 1 August 2022

Sheet Street Surgery is located at:

21 Sheet Street




The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

The practice is situated within the Frimley Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 9,300 patients. Sheet Street Surgery is purpose built and offers spacious and well-equipped surroundings for the delivery of patient care as part of a contract held with NHS England.

The practice is part of a wider network of GP practices called a primary care network (PCN). They belong to the Windsor PCN.

The practice provides medical services to the local community including residents at Winton House care home. The practice is located in a part of Windsor with a small ethnic minority population (12.3%) with most of the patients coming from a white background (87.7%). This area of Windsor has low levels of income deprivation.

The practice clinical team consists of six GP partners and one salaried GP, four practice nurses and a community nurse and two health care assistants. The practice has one clinical pharmacist who is employed by the PCN. The practice is registered as a training practice for doctors who are training to become GPs. At the time of the inspection there was one GP Registrar attached to the practice (A GP Registrar is a fully qualified doctor undertaking training in order to practice as a GP). The clinical team are supported by a practice manager, an assistant practice manager and a reception manager, with the role split between two members of staff, and a team of administration and reception staff.

The practice is open between 8am and 6pm Monday to Friday. Appointments are offered during all opening hours. The practice also offers five and a half hours of extended service from Tuesday to Friday. These appointments begin at 7am on Tuesdays, Wednesdays and Thursdays and 7.30am on Fridays. Patients are also able to access care at the King Edward VII Hospital, Windsor, via a PCN operated primary care hub which offers GP, paramedic, phlebotomy and cervical screening appointments in the evening and at the weekend.

The practice has opted out of providing out of hours services to their patients. Out of hours services are provided by East Berkshire Primary Healthcare. The out of hours service is accessed by calling 111. There are arrangements in place for services to be provided when the surgery is closed, and these are displayed at the practice and in the practice information leaflet.

Overall inspection

Requires improvement

Updated 1 August 2022

We carried out an announced inspection at Sheet Street Surgery on 13 June 2022. Overall, the practice is rated as Requires improvement.

We rated the key questions as follows:

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires improvement

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Sheet Street Surgery on our website at www.cqc.org.uk.

This was a focussed inspection which included the key questions safe, effective and well-led and specific questions from responsive to find out whether patients could access services effectively and in a timely manner.

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 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 Requires Improvement overall. We rated the key question effective as Good and the providers’ previous ratings of Good for caring and responsive services remain because we did not inspect those key questions due to this inspection using a focussed methodology. However, we rated the practice as Requires Improvement for providing safe and well-led services because:

  • Children and vulnerable adults were not safeguarded from the risk of abuse because we found examples of staff who did not have Disclosure and Barring Service (DBS) checks and those staff were continuing to work at the service.
  • The provider did not hold records of immunisation for staff except Hepatitis B for clinical staff.
  • Premises health and safety risks were not managed appropriately or responded to in a timely manner.
  • The fire safety risk assessment had not been repeated within the recommended timeframe and not all risks identified in the overdue risk assessment had been completed.
  • Systems to support governance and management existed but were not always effective because they had not identified non-compliance with best practice guidance and legislation to ensure safe care and treatment was provided to patients.
  • Systems and processes to manage risks were in place, however, in some cases there was no documented risk assessment or action taken in response, we were not assured there was sufficient mitigation in place to ensure services provided to patients were safe.

We found that:

  • Staff learnt from significant incidents when things went wrong.
  • The practice supported parents by giving all unwell children under 10 years of age a same day appointment with a GP.
  • The practice supported patients who were vulnerable by circumstances by ensuring they could register and have access to primary care.
  • 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 listened to concerns and feedback and responded to make improvements to the quality of care and access for patients.
  • Leaders were approachable, compassionate and inclusive.
  • When staff needed advice, guidance or support they felt comfortable to approach leadership and management and were confident action would be taken.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found one breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

In addition, the provider should:

  • Continue to improve access and recalls for patients eligible for cervical screening.
  • Improve the recall of patients with hypothyroidism that require monitoring tests.
  • Prioritise and complete the annual appraisals of nursing staff before commencing appraisals of other staff.

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