19 July 2023
During an inspection looking at part of the service
This service is rated as Good overall. We previously inspected the service in April 2019 when we rated it good overall and for all key questions.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services well-led? – Good
We carried out a focused inspection at The White Rose Surgery in response to provider notifications to us of safety incidents linked to failures and errors in patient referrals. During this inspection we therefore examined the key questions of safe, effective and well-led. The key questions of caring and responsive were not examined and retained ratings of good.
CQC inspected the service in April 2019 and asked the provider to make improvements regarding the need to:
- Review and improve procedures for the date checking of emergency medicines and equipment.
- Review and improve procedures to give greater assurance that consultants had received appropriate annual mandatory training.
- Continue to follow up on actions identified in the last Infection Prevention and Control Audit.
We checked these areas as part of this focused inspection and found these points had been actioned.
The service delivers a range of health and care services including day care, diagnostic services and outpatient clinics and procedures for patients who access the service via an NHS referral. Referrals were either direct into the service or via a sub-contract delivered on behalf of another CQC registered provider.
At the time of the inspection the provider was in the process of appointing a new 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:
- The provider had systems in place to manage the safe and effective delivery of services.
- When any adverse incidents occurred, we saw that relevant statutory notifications had been made, thorough investigations had been undertaken and that learning and improvements had been put in place to prevent recurrence.
- The provider routinely reviewed the quality and effectiveness of services provided through clinical audit, and from receipt of patient feedback.
- Governance procedures were in place, and there were plans to strengthen these in the future.
- Care and treatment had been delivered in line with evidence-based guidelines.
- The service had undergone third party audit and accreditation.
The areas where the provider should make improvements are:
- Implement regular structured infection prevention and control audits across the organisation.
- Examine the need to standardise the production of clinical notes in the patient records system to reduce possible delays.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services