28 July 2020
During a routine inspection
We had previously carried out an announced comprehensive inspection at Spring Street Surgery in July 2018 where the practice was rated was inadequate and was placed into special measures. We re-inspected in April 2019 and the practice had made significant improvements and was rated good overall but requires improvement for the safe domain. The full comprehensive reports for the July 2018 and April 2019 inspection can be found by selecting the ‘all reports’ link for Spring Street Surgery on our website
We carried out an announced desk based focused inspection at Spring Street Surgery on 28 July 2020. This was to confirm the practice had carried out their plan to make the improvements required as identified at our previous inspection on 29 April 2019. We are mindful of the impact of COVID-19 pandemic on our regulatory function. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We found that the practice had completed the actions required and was compliant with the regulation.
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 for providing safe care.
Previously the practice was rated as requires improvement for providing safe care because:
- Patient safety alerts were not always recorded as being actioned appropriately.
- Fridge Temperatures had not been recorded on several working days throughout December 2018 and this had not been checked, actioned or raised as a significant event.
- Significant events were being appropriately recorded and actions taken but outcomes were not centrally recorded or dated.
- Staff recruitment files held the appropriate information with the exception of one locum GP file we reviewed.
At this inspection we found:
- The practice was recording all patient safety alerts on to Teamnet (a web-based platform for sharing, exchanging and collaborating in Primary Care) and were recording the required action appropriately.
- The practice had five fridges whose temperature was recorded every working day. Temperatures were recorded onto a paper format but was in the process of being moved to Teamnet.
- Significant events were being appropriately recorded on to Teamnet. This was also used to record the outcomes and dates of the actions required and when completed. We noted that a review of significant events from 2018 – 2019 cycle had been completed and discussed in February 2020 at a practice team meeting.
- Staff recruitment files held the appropriate information.
At our previous inspection we found areas where the practice should try to improve. These were:
- Considering ways to identify more patients who were carers and strengthen ways in which they can be supported.
- Reviewing ways to increase uptake for cervical screening.
- Reviewing meeting structures for non-clinical staff and the frequency of attendance of clinical staff to ensure greater shared learning.
- Review how information is displayed for patients who wish to make a complaint.
The practice had reviewed these, and we found at this inspection:
- The practice had ensured that there was a display in the waiting room for carers, leaflets were also available, and staff were asked if they had local knowledge of patients who might be carers. The new patient form also included a check box for patients who were carers. There was also a carers lead who had contacted patients to ensure that that they were aware of avenues of support open to them. There were currently 168 registered carers (this represented approximately 2.5% of the patient population).
- During the inspection we discussed the impact of COVID-19 on cervical screening and the practice had found a decrease in the number of patients attending. The practice was able to send us their plan to ensure that patients continued to be screened and those that were considered higher risk would be contacted to attend.
- The practice had reviewed their meeting structures and had in a place a structure of meetings for all staff. This included monthly partner meetings, clinical staff meetings (including nurses) and all staff meetings. However, due to COVID-19 the practice had started twice weekly huddle meetings with staff to ensure staff were kept up to date and given the opportunity to raise questions or concerns.
- Complaint information was on display in the waiting area and on the practice website. Information on display included time frames for the practice to respond and contact details for PALS, Healthwatch, Ombudsman, and NHS England.
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