The Care Quality Commission
  • Doctor
  • GP practice

Clarendon Surgery

Overall: Good read more about inspection ratings

Pendleton Gateway, 1 The Broadwalk, Salford, Greater Manchester, M6 5FX (0161) 983 0190

Provided and run by:
Clarendon Medical Practice

All Inspections

16 November 2023

During a routine inspection

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

24th September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Clarendon Surgery and Trinity Medical Centre (Branch Surgery) on 24th September 2015. Overall the practice is rated as Good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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. All opportunities for learning from internal and external incidents were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. They monitored, evaluated and changed the services they offered to suit the needs of their population, increasing resources at peak times to meet demand. This was most apparent in relation to the telephone appointment system which was monitored on a daily basis, with evidence that patient demand, and not the practice, was managing any changes.
  • The practice recorded, reported and shared significant events and complaints with the Clinical Commissioning Group (CCG), at neighbourhood meetings for peer review, support and continual improvement. They were also aware of the requirement to report necessary information to the Care Quality Commission and provided examples where this had been done.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met people’s needs.
  • 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 (PPG).
  • 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. A business plan was in place and high standards were promoted and owned by all practice staff with evidence of team working across all roles.
  • The practice became Investors in People (IPP) in March 1997 and has retained this status. The IIP is an accreditation that recognises the work an organisation does in empowering its employees to be at their best.
  • They have been a training and teaching practice for GP Registrars and medical students for over 20 years.
  • The practice aimed to build on its already developing processes such as data gathering and analysis, Plan Do Study Act (PDSA) cycles and tests of change, all of which were aimed at improving the quality of service provision for patients.

We saw several areas of outstanding practice including:

  • The practice had introduced a telephone appointment system which increased and improved the flexibility of access to appointments. The system was evaluated on a daily basis and changed to meet the demands of the patients, increasing resources at peak times. The practice could demonstrate the impact of this system showing telephone access to a GP within the hour on a daily basis. Also evidenced was a reduction in the number of unattended appointments (DNA rates) and reduced use of the GP out of hours service which was reflected in very positive patient survey results.
  • The practice had a very good skill mix which included advanced nurse practitioners (ANPs) and they were able to see a broader range of patients than the practice nurse. There was a preceptorship programme in place to support new ANPs to the practice.
  • The practice could evidence that events of significance led to changes in working practice which increased safety not only in their own environment but also throughout the CCG including other GP practices and major hospitals.
  • The practice was involved in many initiatives, local and national, around improving patient safety in general practice. These included, PRISM (around medicine safety), The Scottish Patient Safety Programme, Making Safety Visible and General Productive Practice which is designed to help the practice to support and build on quality improvements. This meant that the practice were continually reviewing the safety of their environments, their clinical practice and the services they offered to make sure that patients were treated in a safe and effective way at all times.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice