The Care Quality Commission
  • Doctor
  • GP practice

Claremont Bank Surgery

Overall: Requires improvement read more about inspection ratings

Claremont Bank, Shrewsbury, Shropshire, SY1 1RL (01743) 248244

Provided and run by:
Claremont Bank Surgery

All Inspections

27 November 2023

During a routine inspection

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

30 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Claremont Bank Surgery on 30 November 2015. 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.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

  • Risks to patients were assessed and well managed.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • 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 and strongly positive.

  • Information about services and how to complain was available and easy to understand.

  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The provider was aware of and complied with the requirements of the Duty of Candour.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s 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 practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and discussed with staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice