Claremont Bank Surgery

Updated 12 January 2024

Claremont Bank Surgery is located in Shropshire at:

Claremont Bank
Shrewsbury

Shropshire
SY1 1RL

The provider is a partnership registered with CQC to deliver the regulated activities: diagnostic and screening procedures, maternity and midwifery services, family planning, surgical procedures and treatment of disease, disorder or injury.

The practice is centrally located in the town of Shrewsbury, and is situated within the NHS Shropshire, Telford and Wrekin Integrated Care System (ICS). The practice delivers General Medical Services (GMS) to a patient population of 7,761 people. The practice is part of the Shrewsbury Primary Care Network (PCN), a wider network of GP practices that work collaboratively to deliver primary care services.

Information published by Public Health England reports the deprivation ranking within the practice population group is in the 7th decile (7 out of 10). The higher the decile, the less deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is predominantly white at 96.9% of the registered patients, with estimates of 1.7% Asian, 1% mixed, 0.3% Black, and 0.1% other. The practice has a higher population of older patients compared with the national average.

The practice team comprises of: 5 GPs, 1 lead nurse, 2 practice nurses and 1 nursing associate. The clinical staff are supported by a team of reception and administrative staff and a community care co-ordinator. Patients are able to access a range of staff employed by the primary care network including a physician associate based at the practice, a mental health practitioner, a physiotherapist, pharmacists and social prescribers.

The practice is open Monday to Friday between 8am and 6pm. Patients can also access an extended hours service provided by the PCN during evenings, weekends and bank holidays. Out of hours services are provided by Shropshire Doctors Co-operative Ltd (Shropdoc) via NHS 111.

Further details about the practice can be found by accessing the practice’s website at www.claremontbanksurgery.co.uk

Updated 12 January 2024

We carried out an announced inspection at Claremont Bank Surgery on 27 November 2023. Overall, the practice is rated as Requires Improvement. We rated the key questions:

Safe: Requires Improvement

Effective: Good

Caring: Good

Responsive: Good

Well-led: Requires Improvement

Following our previous inspection on 30 November 2015, the practice was rated as good overall and good across all 5 key questions.

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

Why we carried out this inspection

We carried out this inspection due to the age of the previous rating.

Our focus included:

• Safe, effective, caring, responsive and well led key questions.

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 and in person on site.
• 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.
• Staff questionnaires.
• Feedback from external stakeholders.
• An interview with a representative of the patient participation group (PPG)

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
• information from the provider, patients and other organisations.

We found:

• Safeguarding systems were in place and staff demonstrated a clear understanding of the reporting and recording processes.
• A range of health and safety checks and risk assessments had been carried out to mitigate identified safety risks for patients and staff.
• Staff recruitment checks had not always been carried out in accordance with regulations.
• There was a system for recording and acting on significant events, but this did not always demonstrate learning and improvement.
• The system for recording and acting on safety alerts was not always effective.
• The practice had exceeded the 95% World Health Organisation (WHO) targets for childhood immunisations in 4 out of the 5 indicators and had met the minimum 90% target in 1 indicator.
• The practice cervical screening uptake rate of 81.5% exceeded the national target.
• Not all patients with a potential undiagnosed condition of diabetes had been identified or managed in line with recommended guidance.
• Most staff were up to date with essential training requirements and were provided with good opportunities for learning and development to expand their role of professional practice.
• The practice had a limited programme of quality improvement.
• Patients were treated with kindness, respect and compassion.
• The most recent published National GP Patient Survey results showed the practice results were higher than local and national averages across all 5 indicators for providing caring services.
• Patients had timely access to appointments. The most recent published National GP Patient Survey results showed the practice had significantly exceeded 3 of the 4 indicators and had a positive variation for 1 indicator for providing responsive services compared with local and national averages.
• Most staff told us they felt supported in their work and considered the culture had very recently improved.
• Structures, processes, and systems to support good governance were in place but not fully embedded into practice.
• Processes for managing risks, issues and performance were not always effective.

We found a breach of regulations. The provider must:

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

The provider should:

• Take action to verify and reconcile the safeguarding register to ensure safeguarding information held is accurate and up to date.

• Implement effective staff induction processes.
• Take action to re-establish the patient participation group.
• Take action to ensure that the risk of potential missed diagnosis of diabetes is reduced.
• Implement a programme of targeted quality improvement.

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 Healthcare