Braithwell Road Surgery

Updated 19 August 2022

The provider, Dr Chandra Raolu, registered with the CQC in June 2017. The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and family planning.

The location, Braithwell Road Surgery, is situated within a purpose-built surgery in a building known as Maltby Services Centre in Maltby, Rotherham, S66 8JE. This centre was built in 2008 and provides accommodation for Local Authority offices, leisure facilities and NHS services. The surgery operates over two floors, but all the patient facilities are on the ground floor.

The practice provides General Medical Services (GMS) for 3,673 patients in the South Yorkshire and Bassetlaw Integrated Care System (ICS) area.

The practice is part of a wider primary care network (PCN) of six GP practices providing services to 38,000 patients in Rotherham. The practices work together with a range of local providers, including across primary care, community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations.

The practice has a principle male GP and employs a regular locum GP. The nursing team comprises of one advanced nurse practitioner, a practice nurse and a health care assistant. There is a practice manager and administration and reception teams.

The practice reception hours are 8am to 6.30pm - Monday to Friday. Surgery times are 8am to 6.30pm Monday to Friday.

Longer appointments are available for those who need them, and home visits and telephone consultations are available as required.

Extended hours services are accessed via the practice for pre-bookable evening appointments 6.30pm to 8.30pm and Saturday and Sunday morning appointments provided at local hub surgeries or via NHS 111.

The National General Practice Profile states that 98.2% of the practice population is from a White background with a further 1.8% of the population originating from Asian, black, mixed or other non-white ethnic groups. Information published by Public Health England, rates the level of deprivation within the practice population group as two, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

Updated 19 August 2022

We carried out an announced inspection at Braithwell Road Surgery on 7 and 12 July 2022. Overall, the practice is rated as Good.

Safe - Good

Effective – Good

Response – Inspected not rated

Well-led - Good

Following our previous inspection on 30 September 2021, the practice was rated Good overall and for all key questions but requires improvement for providing safe services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Braithwell Road 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:

• Breaches of regulations and recommendations identified in the previous inspection
• Ratings carried forward from the previous inspection

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 interviews with the provider 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.
• Patients received effective care and treatment that met their needs.
• The practice had maintained their focus on provision of patient centred care throughout the pandemic and there were high levels of patient satisfaction with all aspects of the care and ease of access.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. We found the previous areas of concern had mostly been addressed and systems had improved

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

• Continue the process to obtain and record Information on staff vaccination status staff in line with the Department of Health Immunisation against infectious disease guidance (the Green Book).
• Continue the process of supporting staff to complete required training.
• Continue the process to implement a patient participation group to improve patient engagement.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services