Elsdale Street Surgery

We carried out an announced inspection at Elsdale Street Surgery from 11 April to 25 April 2022. Overall, the practice is rated as requires Improvement.

The ratings for each key question were

Safe - Good.

Effective - Requires Improvement.

Caring - Good

Responsive – Good

Well-led - Requires Improvement.

Why we carried out this inspection

This inspection was a comprehensive inspection and the providers first inspection following their registration on 14 April 2020.

How we carried out the inspection/review

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
• 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 requires Improvement overall

We found that:

• We found some staff had not been allocated clear responsibilities and roles, this meant that the systems in place to ensure good governance were sometimes ineffective. For example, infection prevention and control, medicines management, significant events and the management of patient safety alerts, staff training and the updating and management of patient records.
• 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.
• There was compassionate, inclusive and effective leadership at all levels.
• The practice had a clear vision and credible strategy to provide high quality sustainable care.
• The practice had a culture which drove quality sustainable care.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

Whilst we found no other breaches of regulations, the provider should:

• Continue to improve the uptake of childhood immunisations.
• Continue to improve the uptake of cervical screening.
• Review the online access to services to confirm that no patients are excluded.
• Update the registration and de-registration of patients on the patient record system to confirm they did not affect patient care.
• Review the arrangements at the reception desk to improve confidentiality.

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