Witton Street Surgery

We carried out an announced focused inspection at Witton Street Surgery on 29 January 2020. We carried out an inspection of this service to follow up on a breach of regulations made at the comprehensive inspection on 19 March 2019 where the service was rated Good overall but Requires improvement for providing safe services. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

• Safe
• Effective
• Well Led

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 action had been taken to address the breaches identified at the last inspection on 19 March 2019 and we have rated this practice as Good overall and Good for all population groups.

We rated the practice as Good for providing safe, effective and well-led services because:

• There were systems in place to promote safe working practices and the safety of patients.
• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
• Staff worked together and with other organisations to deliver effective care and treatment.
• There was good communication between staff and staff told us they felt well supported.

• The practice sought the views of patients and staff and acted on them.
• There was a focus on continuous improvement.

The areas where the provider should make improvements:

• Continue with audits to monitor whether staff have received relevant immunisations appropriate for their role.

• Fire marshal training to be provided to staff with this responsibility.
• The significant event record to record when actions have been completed.
• The results of patient blood tests that have been accessed through the records held by the anticoagulant clinic to be consistently recorded in patients records. This should be audited to ensure the revised policy is followed.
• A record listing each safety alert and the action taken would make it easier to review this information.

• Steps should be taken to prevent the plugs to the vaccine fridges being accidentally disconnected from the power supply.
• A more planned approach to quality improvement should be put in place.
• Provide formal training to non-clinical staff in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).
• Continue to encourage patients to join the 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

We carried out an announced comprehensive inspection at Witton Street Surgery on 19 March 2019 as part of our inspection programme.

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 have rated this practice as good all population groups.

We rated the practice as requires improvement for providing safe services because:

• The systems for monitoring medicines needed to be more robust.

We rated the practice as good for providing effective, caring, responsive and well-led services.

We found that:

• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff were provided with the training and support required for their roles.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice monitored patient access to services. They adjusted access to ensure that it met the needs of patients.
• The practice organised and delivered services to meet the needs of patients.
• There was a system in place for investigating and responding to patient feedback including complaints.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The area where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Provide guidance to all staff on the updated safeguarding policies and procedures.
• Monitor the system to record spot checks of the cleaning undertaken by the cleaners and to record when equipment and clinical areas are cleaned.
• Record all significant events on one record to enable patterns and trends and progress to be more easily identified.
• Review the system to monitor safety alerts.
• Introduce a comprehensive programme of quality improvement and use this information about care and treatment to make improvements.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice