Archived: Nicholstown Surgery

We carried out an announced comprehensive inspection at Nicholstown Surgery on 20 November 2019 as part of our inspection programme.

This service is registered with Care Quality Commission (CQC) under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The chief executive officer is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were:

• Staff had the information they needed to deliver safe, effective and holistic support to patients.
• Patients received coordinated and person-centred care.
• Patients had timely access to appointments through the enhanced access to services system.
• Staff treated patients with kindness, respect and compassion.
• We received 64 comment cards specific to Nicholstown Surgery. All comments were positive about the care they received and access to the service for treatment.
• The provider organised and delivered services to meet patients’ needs.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.
• Staff felt supported to engage in further training as required in order to successfully undertake their role.
• There were clear systems and processes in place to keep people safe and safeguarded from abuse.
• Staff had the information they required in order to deliver safe holistic care to patients even when the clinician had not seen the patient previously.
• There were clear documented processes in place to record significant events and share learning from these.
• The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.

The areas where the provider should make improvements were:

• Consider including all staff in quality improvement activities.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care