St Lawrence Road Surgery

We carried out an announced inspection at St Lawrence Road Surgery on 19 and 30 August 2022. The practice is rated as Good in the key questions safe, effective, caring, responsive and well-led. Overall, the practice is rated as Good.

This was the first inspection of St Lawrence Road Surgery since it joined Derbyshire Community Health Services NHS Foundation Trust.

Why we carried out this inspection.

This inspection was a comprehensive inspection and included the key questions safe, effective, caring, responsive and well-led.

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
• 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 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:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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.

We found one area of outstanding practice:

• The provider had introduced an effective quality assessment programme called Quality Always which assessed and risk rated key areas of practice across the whole practice. Where issues were identified, action plans were put in place to drive improvements. For example, infection prevention, patient safety and protecting vulnerable people.

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

• Add alerts to the electronic records of children with a safeguarding concern.
• Hold completed cleaning schedules within the practice to enable staff to have oversight of the effectiveness of the cleaning. Inform practice staff of how to access the completed schedules.
• Update processes for checking that when a blood test is requested the result is received by the practice.
• Update processes for acting on Medicines and Healthcare products Regulatory Agency (MHRA) alerts to include a recall system or background searches for historic MHRA alerts.
• Review the coding and signing process for patients with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision in place.
• Forward statutory notifications to the CQC when any incident is reported to, or investigated by, the police.

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