The Royal Well Surgery

Updated 15 September 2022

The Royal Well Surgery is located in Cheltenham at:

St Paul's Medical Centre
121 Swindon Road
Cheltenham
GL50 4DP

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

The Royal Well Surgery is within the NHS Gloucestershire Integrated Care Board (ICB) and provides services to approximately 6,800 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.

The practice is co-located with three other GP practices at St Paul’s Medical Centre and they are part of the St Pauls Primary Care Network (PCN) comprising of themselves and the four other GP practices located within the building. One of the practice partners is also the Clinical Director of the PCN as well as the practice being the lead practice for the PCN. They share the care of the local asylum seekers and migrants in a local bridging hotel with another St Pauls PCN practice.

Information published by Public Health England shows that deprivation within the practice population group is in the seventh lowest decile (seven of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 3.4% Asian, 94% White, 0.6% Black, 1.6% Mixed, and 0.3% Other.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

The practice has a team of four GP Partners, two salaried GP’s, with two GP registrars attached to the practice. A team of two practice nurses provide nurse led clinics for long-term conditions. The practice also employs a health care assistant (HCA).The clinicians are supported at the practice by a team of reception/administration staff, three care navigators,the practice manager and deputy practice manager.

The practice is open between 8.30am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone and video consultations and advance appointments.

Outside of these times patients are directed to contact the out-of-hours service by using the NHS 111 Number.

Updated 15 September 2022

We carried out an announced inspection at The Royal Well Surgery on 12 and 13 July 2022. Overall, the practice is rated as Good.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 31 October 2019 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 The Royal Well Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

The CQC is currently undertaking a ‘Band 1 Quality Sampling review’ of practices rated Good/Outstanding. In each sector we are undertaking a percentage of inspections of band one services with published statements and are a key part of our quality assurance of the new monitoring approach. 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

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 facilities
• 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

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 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.

However:

• Staff were not always trained to appropriate levels for their role in infection prevention and control
• The practice did not always appropriately monitor the prescribing of controlled drugs.
• The practice did not always have an effective recall process to follow up on patients who did not attend reviews for high-risk drugs or long term conditions.
• The practice did not always record discussions around a patient’s mental capacity to make a decision when appropriate.
• The percentage of children aged five years who have received immunisation for measles, mumps and rubella did not meet the World Health Organisation (WHO) target of 95%.
• The practice percentage of persons eligible for cervical cancer screening at a given point in time did not meet the national target of 80%.
• The practice did not always involve the public to sustain high quality and sustainable care.

We found one breach of regulations. The provider must:

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

The areas where the provider should make improvements are:

• Accurately record discussions around patient capacity.
• Increase the uptake of children aged five years to receive the immunisation for measles, mumps and rubella.
• Continue to increase the uptake of cervical cancer screening for eligible patients.
• Implement a mechanism to increase patients being able to provide feedback and contribute to the development of the service, for example, the creation of a patient participation group.

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