The Care Quality Commission
  • Doctor
  • GP practice

St Thomas Road Surgery

Overall: Good read more about inspection ratings

St Thomas Road, Featherstone, Pontefract, West Yorkshire, WF7 5HE (01977) 801363

Provided and run by:
St Thomas Road Surgery

All Inspections

06 October 2022

During a routine inspection

We carried out an announced comprehensive inspection at St Thomas Road Surgery on 5 and 6 October 2022. Overall, the practice is rated as Good.

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection in January 2016, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Doctors David Geoffrey Roberts and Deborah Ann Wakefield on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive inspection due to the length of time since the last inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting some staff interviews using video/telephone 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 to the surgery.
  • Speaking with patients and reviewing their feedback.

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:

  • 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 service had systems in place to manage risk so that if safety incidents occurred, they were investigated and any learning from them was shared and used to improve the service and prevent the recurrence of similar issues.
  • Safeguarding systems, processes and practices had been developed, implemented and communicated to staff.
  • Staff informed us that they had access to policies, procedures and guidance relevant to their role and responsibilities, including clinical protocols and guidance.
  • The provider had appropriate clinical equipment in place to enable the effective assessment of patients. The provider also had the necessary equipment and medicines available to deal with medical emergencies including emergency resuscitation equipment.
  • Infection prevention and control was appropriately managed to help safeguard people from COVID-19 and healthcare associated infections.
  • There were processes in place to coordinate, monitor and respond to the clinical needs of presenting patients.
  • Quality and performance was routinely monitored.
  • Patients spoken with had a positive view of the care and treatment they had received.
  • The provider had an effective governance system in place that enabled ongoing monitoring and scrutiny of the operation and performance of the services provided.
  • There were effective communication systems in place to facilitate information sharing across the organisation.
  • Staff told us that the management team was approachable, and that they felt well supported.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

In addition, the provider should:

  • Make improvements to increase the uptake of cervical screening.
  • Formalise clinical supervision practices for non-medical prescribers.
  • Improve the quality of medicine reviews to ensure that details of discussions and decisions are recorded, and whether specific monitoring requirements have been checked.

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

26 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Doctors David Geoffrey Roberts and Deborah Ann Wakefield on 26 January 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • Patients said they were treated with compassion, dignity and respect.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they generally found it easy to make an appointment with a named GP and that there was continuity of care, 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 the the requirements of the Duty of Candour (the intention of this duty is to ensure that providers of health and care services are open and transparent with people who use these services when for example errors are made or harm caused).

We saw one area of outstanding practice:

  • The practice ran a weekly dizziness/vertigo clinic led by one of the GP partners. The clinic identified patients with conditions which effected balance such as benign paroxysmal positional vertigoand offered patients advice in how to manage episodes of dizziness and vertigo when these occurred. In the last four years the practice had dealt with around 1,200 patients (around 1,100 of whom are referred from other practices in the Wakefield area).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24 February 2014

During an inspection looking at part of the service

We did not speak with people who used the service at this inspection because we were checking whether improvements had been made in relation to the recruitment of staff.

We spoke with the practice manager who told us the practice had not employed any new members of staff since the last inspection. We therefore checked whether the recruitment policy was up to date and discussed with the practice manager how they would ensure a robust recruitment process would be followed.

We will also again consider the recruitment of staff at the next scheduled inspection.

5 November 2013

During a routine inspection

We spoke with nine patients and they were happy with the care and treatment they received. One patient said; 'The reception staff are great and treat me with respect.' Another patient told us; 'The care me and my family get is really good and we feel respected here.'

Patients expressed their views and were involved in making decisions about their care and treatment. Patients were given information and support regarding their treatment options.

The practice had clear information about how to safeguard children and vulnerable adults. The majority of the seven members of staff we spoke with were aware of what to do if they suspected abuse was happening. Although it was acknowledged by the safeguarding lead that 'We don't do as much for adult safeguarding.'

We looked at how new staff were recruited and this included a review of three staff records for staff recruited within the last seven months. The recruitment policy stated a job offer would be subject to receipt of satisfactory references and Criminal Records Bureaux (CRB) check. This has now been replaced by the Disclosure and Barring Service (DBS) check. All three members of staff had either started employment prior to either references or a DBS check being obtained. We found appropriate checks were not undertaken before staff began work.

The majority of patients we spoke with knew what to do if they wished to make a complaint. The members of staff we spoke with informed us they were aware of the steps to take if a complaint was made directly to them.