23 November 2022
During an inspection looking at part of the service
We carried out unannounced focused inspection at St Ann's Road Surgery on 23 November 2022 to follow up on concerns received regarding the practice. We looked at the Well-led key question to review elements of the overall running of the practice.
Safe - not inspected
Effective - not inspected
Caring - not inspected
Responsive - not inspected
Well-led – inspected but not rated
Following our previous inspection on 31 October 2017, the practice was rated good overall and for all key questions.
The full report for previous inspections can be found by selecting the ‘all reports’ link for St Ann's Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up concerns reported to us. We looked at a range of issues. These included clinical staffing arrangements and appointment capacity. We reviewed appointment triaging processes and discussed the workplace culture with staff. We did not identify any breaches of regulation during our inspection. This report is not rated and does not change the current ratings held by the practice.
How we carried out the inspection
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.
- Reviewing staff rotas.
- Reviewing policies.
- 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 found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- 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.
Whilst we found no breaches of regulations, the provider should:
- Review the effectiveness of staff training, to be assured that learning is embedded.
- Review the way telephone contacts with patients are captured, to be assured that potential issues of concern are recorded on the patient record.
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 Hospitals and Interim Chief Inspector of Primary Medical Services