The Care Quality Commission
  • Doctor
  • GP practice

Sheet Street Surgery

Overall: Requires improvement read more about inspection ratings

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

Provided and run by:
Sheet Street Surgery

All Inspections

13 June 2022

During an inspection looking at part of the service

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

We have not revisited Sheet Street Surgery, as part of this review because it was able to demonstrate that it was meeting the standards without the need for a visit.

During a routine inspection

Letter from the Chief Inspector of General Practice

In April 2016, during our previous comprehensive inspection of Sheet Street Surgery, we found issues relating to the safe delivery of healthcare services at this practice. As a result of this inspection, we asked the practice to make further improvements; in order to ensure that fire safety procedures and checks are fully implemented. In addition the practice was asked to develop an action plan to address the issues identified during their most recent fire risk assessment.

We also found that the practice did not have an appropriate process for the handling of blank prescription forms. Furthermore, the practice needed to ensure that all staff had undertaken training including safeguarding, health and safety, equality and diversity, fire safety, infection control and basic life support.

We also found that the practice needed to develop and implement a clear action plan to improve the outcomes for patients with learning disabilities, patients experiencing poor mental health and patients at risk of unplanned admission. The practice also needed to encourage carers to register as such, in order to enable them to access the support available via the practice and external agencies.

Finally at our previous inspection, we also found that the practice needed to ensure partnership details are updated to the practices Care Quality Commission (CQC) registration.

Following the last inspection, the practice was rated as requiring improvement in safe services, and good for effective, caring, responsive and well led services. The practice had an overall rating of good.

We carried out a desk based inspection in November 2016 to ensure the practice had made improvements since our last inspection. The practice sent us evidence in the form of fire policies and procedures, and documents relating to the tracking and monitoring of prescriptions, to demonstrate the range of improvements they had made, since our last visit. The practice also further supplied a chart outlining the areas the practice had attempted to improve and an updated staff training record document.

We found the practice had made improvements since our last inspection in April 2016.

At this inspection we found that:

  • The practice had instructed an independent company to re-assess the risk of fire in the practice.

  • The practice had reviewed and updated their fire policy.

  • Improvements had been made to the processes used to handle blank prescriptions.

  • Steps had been taken to address the security issues surrounding blank prescriptions.

  • Systems were now in place to ensure the processes used to handle blank prescriptions were both safe and effective.

  • Staff had undergone training in a wide range of areas. Including safeguarding, equality and diversity, fire safety, infection control and basic life support.

  • The practice had supplied a copy of their training records, to demonstrate the steps taken to improve the previous training issues found.

  • Systems were now in place to monitor training.

  • Steps had been taken to improve the outcomes for patients with learning disabilities, patients experiencing poor mental health, and patients at risk of unplanned admission.

  • Action had been taken to encourage carers to register as such to enable them to access the support available via the practice and external agencies.

The areas where the provider should make improvements are:

  • Continue to ensure all registration details are up to date on the Care Quality Commission database.

  • Ensure all members of staff complete health and safety training, and address any gaps in training staff may have.

Following this desk based inspection we have rated the practice as good for providing safe services. The overall rating for the practice remains good. This report should be read in conjunction with the full inspection report of 7 April 2016. A copy of the full inspection report can be found at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sheet Street Surgery on 7 April 2016. Overall the practice is rated as good.

Specifically, we found the practice to require improvement for provision of safe services. It was good for providing effective, caring, responsive and well-led services. 

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. The majority of information about safety was recorded, monitored and reviewed.
  • Risks to patients and staff were assessed and well managed in some areas, with the exception of those relating to fire safety procedures, safeguarding training, care planning and prescription safety and security. For example, the practice did not have a fire safety policy in place, fire safety system was not serviced regularly and they were not carrying out regular fire safety checks and drills.
  • We found that completed clinical audits cycles were driving positive outcomes for patients.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However, some staff had not completed health and safety, equality and diversity, fire safety and basic life support training.
  • Patients we spoke with on the day informed us 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 were available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Ensure fire safety procedures and checks are fully implemented, and develop an action plan to address the issues identified during recent fire risk assessment.
  • Ensure the process for the handling of blank prescription forms are handled in accordance with national guidance as these were not tracked through the practice and kept securely at all times.

In addition the provider should:

  • Ensure all staff have undertaken training including safeguarding, health and safety, equality and diversity, fire safety, infection control and basic life support.
  • Develop and implement a clear action plan, to improve the outcomes for patients with learning disabilities, patients experiencing poor mental health and patients at risk of unplanned admission.
  • Encourage carers to register as such to enable them to access the support available via the practice and external agencies.
  • Ensure partnership details are updated to the practice’s Care Quality Commission registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice