The Care Quality Commission
  • Doctor
  • GP practice

The Royal Well Surgery

Overall: Good read more about inspection ratings

St Pauls Medical Centre, Cheltenham, Gloucestershire, GL50 4DP (01242) 215010

Provided and run by:
The Royal Well Surgery

All Inspections

13 July 2022

During an inspection looking at part of the service

We carried out an announced inspection at The Royal Well Surgery on 12 and 13 July 2022. Overall, the practice is rated as Good.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 31 October 2019 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 The Royal Well Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

The CQC is currently undertaking a ‘Band 1 Quality Sampling review’ of practices rated Good/Outstanding. In each sector we are undertaking a percentage of inspections of band one services with published statements and are a key part of our quality assurance of the new monitoring approach. This was a focussed inspection which included the key questions safe, effective and well-led and specific questions from responsive to find out whether patients could access services effectively and in a timely manner.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing facilities
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • 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 have rated this practice as Good overall

We found that:

  • 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 practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

However:

  • Staff were not always trained to appropriate levels for their role in infection prevention and control
  • The practice did not always appropriately monitor the prescribing of controlled drugs.
  • The practice did not always have an effective recall process to follow up on patients who did not attend reviews for high-risk drugs or long term conditions.
  • The practice did not always record discussions around a patient’s mental capacity to make a decision when appropriate.
  • The percentage of children aged five years who have received immunisation for measles, mumps and rubella did not meet the World Health Organisation (WHO) target of 95%.
  • The practice percentage of persons eligible for cervical cancer screening at a given point in time did not meet the national target of 80%.
  • The practice did not always involve the public to sustain high quality and sustainable care.

We found one breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Accurately record discussions around patient capacity.
  • Increase the uptake of children aged five years to receive the immunisation for measles, mumps and rubella.
  • Continue to increase the uptake of cervical cancer screening for eligible patients.
  • Implement a mechanism to increase patients being able to provide feedback and contribute to the development of the service, for example, the creation of a patient participation group.

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

31/10/2019

During a routine inspection

Following our annual regulatory review of the information available to us, we inspected this service on 31 October 2019. The service was last inspected in February 2016. It was rated as good for each of the five key questions and rated good overall. This inspection looked at the following key questions; was the service providing effective and well led services for the registered patient population. We decided not to inspect whether the practice was providing safe, caring or responsive services as there was no information from the annual regulatory review which indicated this was necessary.

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 good for all population groups.

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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Governance systems were robust and regularly reviewed.
  • The practice was engaged in local initiatives and worked alongside partners in the local healthcare system.

We found no breaches of regulations. However, the areas where the practice should make improvement are:

  • Continue to implement actions with a view to improving uptake for the cervical screening programme.
  • Continue to monitor exception reporting data that was outside of the expected range.
  • Continue to support the actions designed to implement the Patient Participation Group.

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

23 February 2016

During a routine inspection

We carried out an announced comprehensive inspection at The Royal Well Surgery on 23 February 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • 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 they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour. (Duty of Candour is a legal duty to ensure providers are open and transparent with patients who use services. It also sets out specific requirements providers must follow when things go wrong with care and treatment, including informing patients about the incident, providing reasonable support, providing truthful information and an apology when things go wrong).

The areas where the provider should make improvement are:

  • Review how the practice identifies carers in order to increase the numbers of patients who may require carer support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice