Swallownest Health Centre

Updated 27 September 2023

Swallownest Health Centre is located at Swallownest Health Centre, Worksop Road, Swallownest, Sheffield, S26 4WD.

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

The practice is situated within the South Yorkshire Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of 16,260. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices under the Rother Valley South Primary Care Network.

Information published by Public Health England shows that deprivation within the practice population group is in the sixth decile (six of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is approximately 97.4% White, 1.0% Asian, 0.9% Mixed, 0.6% Black and 0.2% Other.

The age distribution of the practice population generally mirrors the local and national averages. However, the practice has a larger percentage of older people compared to local and national averages.

There is a team of 4 GP partners and 7 salaried GPs who provide clinical cover. The practice has an advanced nurse practitioner, nurses and healthcare assistants who provide clinics for the management of long-term conditions. The clinical teams are supported at the practice by a team of reception and administration staff. The practice management team provide managerial oversight.

Extended access, where late evening and weekend appointments are available, is provided by the practice in partnership with Connect Healthcare Rotherham CIC. Out of hours services are also provided by Connect Healthcare Rotherham CIC.

Updated 27 September 2023

We carried out an announced comprehensive inspection at Swallownest Health Centre on 5 and 14 June 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective - requires improvement.

Caring – good.

Responsive – good.

Well-led - requires improvement.

Following our previous inspection on 11 and 15 October 2021, the practice was rated requires improvement overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Swallownest Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up breaches of regulation from the previous inspection in line with our inspection priorities.

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 using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A 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:

Improvements had been made since the previous inspection in the following areas:

• Staff had completed the required level of safeguarding training.
• A system had been implemented to monitor the use of blank prescriptions.
• Emergency medicines provision and equipment had improved.

• Improvements had been made to the staff training programme and monitoring systems and staff had undertaken training as required for their role.
• The care of patients with long term conditions.
• Data for 2023 showed improvement in patient satisfaction in most areas.
• Significant changes had been made to systems and processes to improve access and improvements in patient satisfaction with access were seen in the most recent survey.
• Complaints management.

Whilst some improvement had been made further improvement was still required in the following areas:

• Systems to check emergency medicines and equipment were not effective.
• Patients prescribed high risk medicines had not always had monitoring checks at the required intervals.
• Some incidents had not been recorded and records of investigation and action taken were not always complete.
• Although some audit activity was taking place the practice had not developed a formal quality improvement process with an audit plan and where patient surveys had been completed these were not always analysed and action plans for improvement developed.
• Patient satisfaction with telephone access and access to appointments was still below local and national averages.

Additionally at this inspection, we found improvements were required in the following areas:

• Health and safety risk assessments had not been completed to ensure known risks, including those outside of their control, were mitigated as far as possible.
• Evidence to show appropriate action had been taken in response to medicine safety alerts was not always recorded in patient records.

We found one breach of regulations. The provider must:

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

Although not a breach of regulations, the provider should:

• Maintain records of child safeguarding meetings.
• Implement a formal quality improvement process.

• Continue to monitor and improve telephone access and access to appointments.

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 Health Care