The Care Quality Commission
  • Doctor
  • GP practice

Swallownest Health Centre

Overall: Requires improvement read more about inspection ratings

Worksop Road, Swallownest, Sheffield, South Yorkshire, S26 4WD (0114) 433 3888

Provided and run by:
Swallownest Health Centre

All Inspections

5 June 2023 and 14 June 2023

During an inspection looking at part of the service

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

11-15 October 2021

During a routine inspection

We carried out an announced inspection at Swallownest Health Centre between 11 and 15 October 2021. Overall, the practice is rated as requires improvement:

  • Safe – requires improvement
  • Effective - requires improvement
  • Caring - requires improvement
  • Responsive - requires improvement
  • Well-led - requires improvement

Following our last comprehensive inspection on 15 June 2016, the practice was rated good overall and for the effective, responsive and well-led key questions. We rated the caring key question as outstanding and the safe key question as requires improvement. We undertook a follow-up focused inspection on 21 June 2017 to review the safe key question. During that inspection, we saw the required improvements had been made and rated the safe key question as good.

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

This inspection was a comprehensive inspection planned in response to information of concern received by the Care Quality Commission.

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
  • 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
  • Conducting an electronic staff questionnaire
  • Reviewing patient feedback

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 requires improvement overall.

We found that:

  • The practice did not have clear systems to keep people safe and not all staff had undertaken the required safeguarding training for their role.
  • There was not a comprehensive mandatory training programme in place, and not all staff had undertaken mandatory and recommended training as required for their role, including recommended training in basic life support, resuscitation and sepsis awareness.
  • The practice did not have adequate procedures in place for the management and oversight of emergency medicines, emergency medical equipment and oxygen.
  • The practice lacked a comprehensive and established procedure to govern the management of blank prescription forms.
  • The practice’s systems for the appropriate and safe use of medicines and the management of patients prescribed high risk medicines required review.
  • The practice did not have an established incident reporting process in place to ensure all categories of incidents were reported and investigated appropriately.
  • The practice did not have effective and established processes in place for the management and monitoring of patients with long-term conditions.
  • Feedback from patients on the care they received from the service was not always positive.
  • The practice did not resolve or investigate complaints in line with their policy.
  • Appointment availability and telephone access required review.
  • The practice did not have clear and effective processes for managing risks, issues and performance, and leaders did not always demonstrate they had the capacity and skills to deliver high quality sustainable care.

However:

  • Appropriate standards of cleanliness and hygiene were met.
  • Childhood vaccinations and immunisations were largely above required targets.
  • Staff were proactive in helping patients to live healthier lives.
  • The practice obtained consent to care and treatment in line with legislation and guidance.

We found three breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure all premises and equipment used by the service provider is fit for use.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Although not a breach of regulations, the provider should:

  • Improve telephone access to the practice.
  • Improve availability of appointments so patients can access care and treatment when they require it.
  • Implement a formal quality improvement and continuous improvement process.

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

21 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Swallownest Health Centre on 15 June 2016. The overall rating for the practice was Good with requires improvement for safety. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Swallownest Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 21 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • Recruitment had been improved to ensure the necessary employment checks were in place for all staff.
  • Systems to prevent and control the spread of infections had been improved. Staff training and procedures to monitor the standards of cleaning and improve stock control of sterile equipment had been implemented.
  • Blank prescription forms and patient records were securely held.

The provider should make improvements in the following areas:

  • Develop systems to analyse significant events to assist in identifying patterns and trends and to review the effectiveness of action taken to minimise the risk of reoccurrence following an incident.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

15 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Swallownest Health Centre on 15 June 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.
  • There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. However, there was a lack of oversight and monitoring of some areas of health and safety, cleaning standards and stock control. There were also shortfalls in recruitment and records management.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had received training to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, staff had not received infection prevention and control and fire safety training.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Feedback from patients about their care was consistently positive.

  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and continuity of care was a priority for the practice. Urgent appointments were 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.

We saw two areas of outstanding practice:

The practice made continuity of care for patients a priority. For example:

They had arranged the appointments system to encourage continuity of care by providing 50% of their appointments which could be booked up to 12 weeks in advance. All the staff were focused on continuity of care and offered appointments with the patients usual GP where ever possible. Home visits were also arranged with the patients usual GP. Patients told us they could easily book an appointment with a named GP within a reasonable timescale. Data showed 52% of patients could always or almost always see or speak to the GP they prefer compared to the CCG and the national average of 36%.

The practice had also implemented a care home service in a way that gave continuity of care for patients. They had done this by providing a set visit day and time with the same GP. Staff at the care home attended by the practice confirmed the arrangements and said the practice concentrated on providing consistency for patients. They said the GP responsible for the home was always available by telephone or email. The home manager was also invited to the practice monthly multidisciplinary meeting to discuss the care plans for their patients. They told us this arrangement worked to the benefit patients and their families and they gave examples of positive care outcomes for patients related to the continuity of care provided. They said this service had reduced admissions to hospital and the need for patients to attend the accident and emergency department and use of the out of hour’s service. The practice had provided this initiative for a number of years, initially without any extra remuneration, although since April 2016 Rotherham CCG had provided extra payments for care home patients as an enhanced service.

The areas where the provider must make improvement are:

  • The practice must take immediate action to ensure its recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff.

  • Ensure systems to prevent and control the spread of infections are improved such as providing staff training and implementing procedures to oversee and monitor the standards of cleaning and stock control of sterile equipment.

  • Securely store prescription forms held in GP consulting rooms.

The areas where the provider should make improvement are:

  • Develop and implement systems, such as written protocols, so learning from significant events is cascaded to new staff and supports staff when dealing with the same situation in the future.
  • Develop and implement systems to review the effectiveness of action taken to minimise the risk of reoccurrence following an incident.
  • Securely store patient records held in GP consulting rooms.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

18 November 2013

During a routine inspection

Patients expressed their views and were involved in making decisions about their care and treatment. We saw that patients were given information and support with regards to treatment options and that staff maintained patient's privacy and confidentiality.

We spoke with ten patients including a representative of the 'Patient Participation Group' (PPG) they told us they were treated with respect and the care they received was 'Very good.' Patients told us they were very happy with their experience of the practice and said the practice nurses were very thorough and explained everything to them. One patient said, 'I find the practice is very good at responding to medical emergencies, I phoned up this morning, told them my problem and I was given an appointment straight away.'

We found the environment to be clean, tidy and organised. We saw there were appropriate systems in place to reduce the risk and spread of infection. Patients said 'The practice is clean and modern, the facilities are excellent.'

Staff had received appropriate professional development and training to ensure they could meet the needs of the patients who used the service.

Staff were familiar with the procedures to report any issues or abuse of patients.

The practice had systems in place to assess and monitor the quality of the service that patients received. One patient said, "I am involved in improving the patient experiences at the practice, and we are getting there, it's very good."