24 May 2022
During a routine inspection
We carried out an announced inspection Oliver Street Surgery on 24 May 2022. Overall, the practice is rated as good.
The ratings for each key question are:
Safe - Good
Effective - Good
Well-led - Good
Following our previous inspection on 12 April 2016, 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 Oliver Street Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up on:
- Key questions inspected
- Ratings carried forward from previous inspection
How we carried out the inspection/review
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
- 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:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The practice building was owned and maintained by NHS Property Services who were responsible for risk assessments and completing identified actions. The practice had oversight of the risk assessments.
- Actions had been completed in response to the infection prevention and control (IPC). audit. An action plan was in place to carry out other work such as replacement flooring and coat hooks for patients clothing.
- 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. Additional appointments were offered on a Saturday as required, to clear backlogs for cervical screening and childhood immunisations.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice had developed a multi-disciplined partnership to lead the practice.
- The practice identified learning from significant events both positive and negative.
- The practice kept a record of staff vaccinations for clinical staff. For non-clinical staff they recorded their flu and COVID-19 vaccinations. However, the practice did not hold records of other recommended vaccinations such as varicella, tetanus, diphtheria, polio and measles, mumps and rubella (MMR) for non-clinical staff.
- The practice had an informal approach to the overview of non-medical prescribers. The GPs were available for the non-medical prescribers to discuss any concerns. Immediately following the inspection, the practice put a formal process in place to audit the prescribing practice of the non-medical prescribers.
Whilst we found no breaches of regulations, the provider should:
- Continue completing identified actions as a result of the IPC audit.
- Obtain documentary evidence that staff have received appropriate vaccinations in line with current UK Health and Security Agency (UKHSA) guidance if relevant to role.
- Embed the process in place to audit the prescribing of the non-medical prescribers.
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