Background to this inspection
Updated
4 May 2020
St Ann’s Medical Centre is located at Rotherham Health Village, Doncaster Gate, Rotherham, S65 1DA and has branch surgeries at Kimberworth Park Road, Rotherham, S61 3JN and at Ridgeway Medical Centre, Rotherham, S65 3PG.
The practice is registered with the CQC to carry out the following regulated activities - diagnostic and screening procedures, surgical procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.
The practice has a contract with the NHS Rotherham Clinical Commissioning Group (CCG) which is made up of 30 general practices. The practice provides Personal Medical Services (PMS) and offers enhanced services for various immunisation checks.
The practice is a member of the location primary care network of GP practices. At the time of our inspection there were 17,706 patients on the practice list.
The practice has ten female GPs, three male GPs, two advanced nurse practitioners, an emergency care practitioner, three practice nurses, three healthcare assistants, a phlebotomist, a business manager, a deputy manager and an extensive reception and administrative team.
St Ann's Medical Centre is in one of the most deprived areas of Rotherham. The practice catchment area is classed as being within one of the most deprived areas in England. The practice scored one on the deprivation measurement scale; the deprivation scale goes from one to 10, with one being the most deprived. People living in more deprived areas tend to have greater need for health services. National General Practice Profile describes the practice ethnicity as being 85.6% white British, 10.1% Asian, 1.6% black, and 1.5% mixed and 1.1% other non-white ethnicities. The practice demographics show a slightly higher than average percentage of people in the 75+ year age group. Average life expectancy is 77 years for men and 81 years for women compared to the national average of 79 and 83 years respectively. The general practice profile shows that 65.4% of patients registered at the practice have a long-standing health condition, compared to 55% locally and 52% nationally.
Updated
4 May 2020
We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
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 and for all population groups apart from working age people which is rated as requires improvement.
We rated the practice as
requires improvement
for working age people becau
se:
-
Performance data was significantly below local and national averages for cervical cancer screening.
Whilst we found no breaches of regulations, the provider
should
:
- Continue to review the use of appropriate coding within the patient record system to promote consistency.
- Continue to review the uptake of cervical cancer screening with a view to improving achievement.
We saw two areas of outstanding practice:
-
Following management changes, a whole practice review was undertaken. Areas for improvement were implemented as part of the practice improvement programme. As part of this the practice identified further engagement with patients was required. A Patient Engagement Officer role was introduced and tasked with coordinating patient feedback. As a result of feedback from patients, a six-month probation period was introduced to support and mentor new staff. Staff told us they found this approach welcoming and supportive.
-
The practice review also identified a high level of complaints from patients which were not themed into categories. This was undertaken and as a result, further customer care training was delivered to staff, and care navigation implemented. A telephone call auditing tool was introduced in 2018 to measure the effectiveness and quality of the calls answered at the practice. The results from 2018 demonstrated that 79% of calls audited met the required competencies, whereas the most recent audit in March 2020 demonstrated all the competencies were met. In addition, the number of complaints to the practice had significantly reduced from 24 in 2018 to eight in 2019.
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