Clarendon Surgery

Updated 23 February 2024

Clarendon Surgery is located in Salford at:

1st Floor,
Pendleton Gateway,
1 The Broadwalk,
Salford,
M6 5FX

The practice has a branch surgery at:

Branch Practice

The Angel Medical Practice

St Phillips Place,
Chapel Street,
Salford,
M3 6FA

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures These are delivered from both sites.

The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

Clarendon Surgery is located within the Pendleton Gateway building which opened to the public in 2009. Services inside the building include two GP practices along with community services including district nursing, orthoptics and podiatry, audiology, Salford Child and Adolescent Mental Health Services (CAMHS), a children’s outpatient department, a council information centre for customer queries, a library, community dental services, pharmacy and an x-ray and therapy suite.

The practice delivers General Medical Services (GMS) to a patient population as part of a contract held with NHS England. The practice list size is approximately 10,500 and they are part of Salford ICB with a collective list size of 308,000 patients over 38 GP practices. They are also part of Salford Southeast primary care network which is a of a wider network of GP practices.

Information published by the Office for Health Improvement and Disparities shows that deprivation within the population group is 1 (2 out of 10). The higher the decile the less deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 73.2% white British, 6.7% Asian 11.3% Black and 9% other.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

Clarendon Surgery has struggled with GP recruitment following retirement/relocations in the team. Recruitment has been challenging but the practice has recently successfully employed a new GP. Due to the unprecedented demand on the practice and an ever-increasing list size, recruitment is still underway for a further GP and supporting healthcare professional, such as an Advanced Nurse Practitioner.

There is currently a team of 2 managing partners, 8 associate GPs and an advanced nurse practitioner who provide cover at both practices. The practice has a team of nursing staff made up of 1 practice nurse, an advanced practitioner and 3 health care assistants who provide nurse led clinics and phlebotomy services for long-term condition and other ailments at both the main and the branch locations. The GPs are supported at the practice by a team of pharmacists with a pharmacy lead and a team of practice management, reception and administration staff. The practice manager and assistant practice manager are based at the main location to provide managerial oversight. There are also 2 care co-ordinators and 2 medical secretaries.

The practice is open 8am to 6.30pm Monday to Friday at both locations. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the primary care network, where late evening and weekend appointments are available. Out of hours services are provided by NHS111.

Updated 23 February 2024

We carried out an announced comprehensive inspection at Clarendon Surgery on 16 November 2023. Overall, the practice is rated good.

Safe - good

Effective – good

Caring - good

Responsive - good

Well-led – good

The practice was rated good at the last inspection in 2016.

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

Why we carried out this inspection

We carried out this inspection because of aged ratings and to follow up on information received into the Commission and an aged rating.

We inspected the key questions of safe, effective, caring, responsive and well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter 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 saw several areas of outstanding practice.

• Feedback from people who used the service, those who were close to them, and stakeholders, was continually positive about the way staff treated people. Patients reported, and we saw, that staff went the extra mile and their care and support exceeded expectations. The provider proactively canvassed patient feedback and used this to adapt how services were delivered to enhance experience. We observed staff treated patients with compassion, kindness, dignity and respect during our inspection. We saw various examples of a positive and caring environment where patients thoughts and feelings were considered.
• The practice had implemented and developed a pharmacy team with a lead pharmacy role which had been further developed over the years. The team supported patients by undertaking medication reviews, medication queries, supporting nurses with their face to face clinics, working on the document management system and referencing clinical letters. The lead had been further developed to undertake a queries clinic in the mornings to help with queries received on a day to day basis. The lead delegated work to the team and would oversee and support pharmacy staff to be able to meet patient requirements safely.
• Trainee staff were mentored and underwent assessments where 20 cases were reviewed to ensure they maintained appropriate prescribing standards. Daily clinical meetings supported newly qualified GPs where clinical cases were discussed. Trainees had protected debriefing time blocked on the clinical system. Staff wellbeing was important to the practice. We also saw that the practice was very supportive and caring of its staff, promoting positive health and wellbeing throughout everything they did on a daily basis. They had a mental health first aider available to support all staff either on a one-to-one basis, weekly catch up or whatever suited the individual.

In addition we found:

• 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.
• Patients could access care and treatment in a timely way and the practice continued to make improvements to their appointment system.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

• Check that all staff immunisations are up to date or a risk assessment is undertaken.
• Improve uptake for cervical screening and immunisations.

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 Health Care