Background to this inspection
Updated
11 November 2019
The Crown Surgery is located at 23 High St, Eccleshall. The surgery has good transport links and there is a dispensary at the practice.
The practice is registered with the Care Quality Commission (CQC) as a partnership provider.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury; family planning and minor surgery. However, the practice no longer delivers a minor surgery service and updated their statement of purpose in relation to this.
The Crown Surgery is a member of the NHS Stafford and Surrounds Clinical Commissioning Group (CCG) and provides services to 7850 patients under the terms of a personal medical services (PMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
The provider is a partnership with two male and one female GP partners. The practice also has one salaried GP; two practice nurses; a first contact physiotherapist and a phlebotomist. The practice manager and business support administrator are supported by eight receptionists, five dispensing staff, two secretaries, and and one cleaner.
The practice is open between 08.00 and 6.30pm Monday to Friday. Extended hours through the local hub arrangements are in place until 8.pm Monday to Friday and from 9am to 1pm at weekends. When the surgery is closed the out of hours care is provided by Staffordshire Doctors urgent Care Ltd.
Further information can be found on the practice website: www.crownsurgery.org.uk
Updated
11 November 2019
We previously carried out an announced comprehensive inspection at The Crown Surgery in January 2019 as part of our inspection programme. The practice was rated as good overall but requires improvement in well led.
The practice was found in breach of Regulation 17 Good Governance; specifically, there was no oversight of all safety alerts and action taken in response to these. Appropriate action had not been taken in response to the safety alert on blank plug sockets, which required these to be removed. Appropriate action had not been taken in response to the safety alert on blind stops.
There were limited systems and processes that enabled the registered person to evaluate and improve their practice in respect of processing of information obtained throughout the governance process. In particular: there was no suitable mechanism to ensure that all clinical staff were involved in practice meetings or able to give or receive feedback for the purposes of continually evaluating and improving services. The practice did not share the learning from significant event and complaint reviews with the whole staff team. There was limited evidence of a comprehensive programme of quality improvement. The practice had not ensured the competence of staff employed in advanced roles by audit of their clinical decision making.
Following our review of the information available to us, including information provided by the practice, we carried out an announced focused inspection at The Crown Surgery on 14 October 2019. We focused our inspection on the following key questions: safe; effective and well led. Due to the assurance received from our review of information, we carried forward the ratings for the following key questions: caring and responsive.
The practice had reviewed their processes and met all the requirements of the requirement notice for regulation 17 Good Governance. Additionally, the practice had undergone considerable refurbishment, reviewed its infection prevention and control procedures and established effective cleaning schedules and checks. The practice had adjusted its skill mix with an additional salaried GP, two practice nurses and a first contact physiotherapist.
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 good 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.
- 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Review the arrangements for blank prescription storage and issue.
- Review the storage of emergency medicines.
- Update discussed SOPs to ensure clarity of purpose.
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