Archived: Crown Street Surgery

Updated 18 February 2016

Crown Street Surgery is situated within a purpose built surgery in Mexborough, Rotherham.

The practice provides General Medical Services (GMS) for 9,400 patients in the NHS Rotherham Clinical Commissioning Group (CCG) area.

There are two male GP partners in addition to one male and three female salaried GPs. There are two advanced nurse practitioners, a practice nurse, three trainee practice nurses and two health care assistants. There is an administration team led by a practice manager.

The practice is open at the following times:

• Reception opening times are 8am to 6 .30pm Monday to Friday.
• GP and Nurse team surgeries are 7am to11.20 am and 1pm to5.50pm Monday to Friday.

Out of hours services are provided by Care UK, (the company providing out-of-hours care for NHS Rotherham's patients). Calls are diverted to this service when the practice is closed. NHS Rotherham also provides a Walk-in Centre to deal with minor ailments, illnesses and injuries. It is open from 8am to 9pm every day including Bank Holidays (excluding Christmas Day).

The practice is registered to provide the following regulated activities; maternity and midwifery services; family planning, surgical procedures, diagnostic and screening procedures and treatment of disease, disorder or injury.

We had been notified the practice partnership had changed. A new partner is in the initial stages of registering with the CQC.

Updated 18 February 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crown Street Surgery on 2 December 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 although records of actions taken could be improved.
• Risks to patients were assessed and well managed although records of actions taken in response to environmental risk assessments could be improved.
• 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. Training records could be improved to evidence the in-house training provided.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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.
• 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.

The areas where the provider should make improvement are:

• There were some shortfalls in record keeping for example, records were not always completed to evidence actions had been taken to address any learning points from investigations of significant events. Infection prevention and control training provided in-house was not recorded to evidence the content of the course and completion date. Records were not always completed to evidence action had been taken to address areas identified for improvement in the environmental risk assessment.

• Systems to communicate with staff could be improved. For example, staff did not feel they had the opportunity, as a team, for sufficient regular discussion about the operation of the practice and any changes being implemented.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 18 February 2016

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in the management of long- term conditions and patients at risk of hospital admission were identified as a priority.
• Performance for diabetes related indicators was 96.5% which was better than the CCG and national averages of 82.7% and 89.2%.
• Longer appointments and home visits were available when needed.
• All these patients had a named GP and a structured annual review to check that their health and medicines needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 18 February 2016

The practice is rated as good for the care of families, children and young people.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• The practice uptake for the cervical screening programme was 80.61% which was comparable to the CCG average of 82.5% and the national average of 81.8%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.

Updated 18 February 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• It was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The percentage of people aged 65 or over who received a seasonal flu vaccination was comparable to the CCG and national averages. The nursing team visited patients at home, where required, to provide this treatment to ensure consistency and a personal service.

Updated 18 February 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 18 February 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• 77.5% of people diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months.
• Performance for mental health related indicators was 96.2% which was better than the CCG and national averages of 90.7% and 92.8%. We saw this was an improvement in this area from the practice 2013/14 results of 72.2%.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• Staff had a good understanding of how to support people with mental health needs and dementia.

Updated 18 February 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances those with a learning disability.
• It offered longer appointments for people with a learning disability.
• The practice nurses regularly worked with multi-disciplinary teams in the case management of vulnerable people.
• It had told vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out-of-hours.