The Care Quality Commission
  • Doctor
  • GP practice

Healds Road Surgery

Overall: Good read more about inspection ratings

Healds Road, Dewsbury, West Yorkshire, WF13 4HT (01924) 438222

Provided and run by:
Healds Road Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Healds Road Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Healds Road Surgery, you can give feedback on this service.

17 June 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Healds Road Surgery between 13 June 2022 and 17 June 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 31 August 2016, the practice was rated Good overall, and for all key questions.

The key questions of caring and responsive were not inspected at this most recent inspection and have therefore retained their previous ratings of Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Healds Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection as part of our CQC inspection programme.

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 some staff interviews using video/telephone 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 shorter site visit
  • Staff questionnaires

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:

  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice adjusted how services were delivered to meet the needs of patients during the COVID-19 pandemic. Patients were able to access care and treatment in a timely way.
  • There was a programme of quality improvement, this included both clinical and non-clinical audit.
  • Staff had the skills, knowledge and experience to deliver effective care. The practice had a strong training ethos, and had supported a number of staff in the development of their professional careers.
  • The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Leaders and managers in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.

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

  • Continue to monitor and make improvements to increase the uptake of cervical screening and bowel cancer screening.
  • Monitor and make improvements in respect of the management of antibacterial and hypnotic prescribing.
  • Maintain clear clinical records to document decisions made regarding the continued prescribing of high-risks medicines where the patient had failed to comply with repeated requests to attend for reviews and necessary tests.
  • Continue to monitor and improve health checks offered to specific vulnerable groups.

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

31 August 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Healds Road Surgery on 7 January 2016. The practice was rated as requires improvement for providing safe services. The practice’s overall rating was good. A breach of legal requirements was found.

Following on from the inspection the practice provided us with an action plan detailing the evidence of the actions they had taken to meet the legal requirements in relation to providing safe services to their patients.

We undertook a desk based review on 29 August 2016 and visited the practice on 31 August 2016. This was to review in detail the information the practice had sent to us and to confirm that the practice were now meeting legal requirements. This report only covers our findings in relation to those legal requirements.

The full comprehensive report which followed the inspection in January 2016 can be found by selecting the 'all reports' link for Healds Road Surgery on our website at www.cqc.org.uk.

Our key findings across the areas we inspected were as follows:

  • Systems were in place to effectively manage the safe storage of vaccines.
  • Staff had received training to ensure that the temperature of the vaccine fridges was recorded and staff understood that any temperatures outside of the accepted range for the storage of vaccines must be reported without delay

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Healds Road Surgery on 7 January 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • The practice did not have effective systems to ensure the vaccination fridge was monitored correctly. Past records of maximum temperature readings were consistently above the acceptable range for the storage of vaccines from January to June 2015.
  • Risks to patients were assessed and well managed.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice took a whole team approach to improving outcomes for patients.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff who all had clear responsibilities in relation to the vision.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information about services and how to complain was available and easy to understand.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of outstanding practice:

The practice had increased the uptake of cervical smears from 60% to 72% in the preceding 12 months by employing a bilingual nurse who audited patient uptake, identified barriers to attendance and created an action plan to remove them. As a result patients were actively encouraged to attend, the recall system and invitation letters were reviewed and evening appointments were offered.

The areas where the provider must make improvements are:

  • Implement systems to effectively monitor the temperature of the vaccine fridge and take action where the temperature falls outside accepted range. Ensure the temperature of the vaccine fridge is calibrated at least every month against an independently powered external thermometer.

The areas where the provider should make improvements are:

  • Ensure the practice has a system for production of Patient Specific Directions (PSDs) to enable Health Care Assistants to administer vaccinations
  • Ensure information is available to complainants about how to take action if they are not satisfied with how the provider manages and/or responds to their complaint.
  • Ensure there are systems and processes that assure compliance with statutory requirements and safety alerts.
  • Ensure policies and procedures are up to date and in line with current legislation and guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice