The Care Quality Commission
  • Doctor
  • GP practice

Spa Surgery

Overall: Good read more about inspection ratings

205 High Street, Wetherby, West Yorkshire, LS23 6PY (01937) 842842

Provided and run by:
Spa Surgery

All Inspections

23 November 2023

During a routine inspection

We carried out an announced comprehensive inspection at Spa Surgery on 22 and 23 November 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 1 February 2017, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was due to the length of time since the last inspection.

This inspection was a comprehensive inspection, therefore we inspected all of the following key questions:

Safe

Effective

Caring

Responsive

Well-led

How we carried out the inspection/review

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 in person and using video conferencing.
  • Staff questionnaires circulated prior to the inspection.
  • 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.
  • Reviewing feedback from patients via the CQC share your experience forms.
  • A short 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 found that:

  • 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. The majority of feedback we received from patients was positive about the way they were treated by staff at the practice.
  • Patients could access care and treatment in a timely way.
  • The practice was responsive to the needs of the local population and tailored services in response to patient needs. For example, the practice offered an in-house Women’s Health Clinic to support patients with symptoms of perimenopause and menopause.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

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

  • Improve the system for adding alerts to family members of patients on the safeguarding register.
  • Improve the process for capturing immunisation of non-clinical staff in line with The Green Book Immunisation Against Infectious Diseases.
  • Review and complete actions identified as part of the fire risk assessment on completion of the building works.

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

1 February 2017

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 Spa Surgery on 14 July 2015. The overall rating for the practice was good. However; we rated the practice as requires improvement for providing safe care The full comprehensive report on the July 2015 inspection can be found by selecting the ‘all reports’ link for Spa Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 1 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the issues that we identified in our previous inspection on 14 July 2015. This report covers our findings in relation to those requirements.

The practice has now met the legal requirements in the key question of safe and is now rated as good.

Our key findings were as follows:

  • Risks to patients were assessment and well managed. The practice had implemented Disclosure and Barring Service (DBS) checks for all clinical staff and those acting in the role of a chaperone. Risk assessments were in place for all non-clinical staff to outline why a DBS check had not been conducted.
  • The practice had carried out risk assessments in relation to fire; health and safety and legionella. Actions identified as a result of the assessments had been addressed.
  • We reviewed the staff files of two recently recruited staff members and found appropriate checks had been undertaken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Spa Practice on 14 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for all the population groups. It required improvement for providing safe services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff told us they had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • Patients said there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by the partnership. The practice proactively sought feedback from staff and patients, which it acted on.
  • Some risks to patients were assessed and managed, with the exception of those relating to recruitment checks and legionella testing

However, there were areas of practice where the provider should make improvements.

  • Ensure recruitment arrangements include all necessary pre-employment checks.
  • Ensure a legionella test is completed and action plan implemented in accordance with the findings.
  • Ensure risk assessments are appropriately documented and recorded and updated as necessary.
  • Keep a record of all training and updates staff attend.
  • Comply with fire safety regulations by performing fire evacuation drills as required.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice