20, 23 and 28 June 2023
During an inspection looking at part of the service
At our previous inspection, from the 11 to 25 April 2022, where the surgery was rated requires improvement overall and for the key questions of effective and safe, all other key questions were rated good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Elsdale Street Surgery 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. We reviewed the key questions of safe, effective, responsive and well-led.
We carried out an announced focused follow up inspection at Elsdale Street Surgery on the 20, 23 and 28 June 2023 and rated the surgery as Good overall. The key questions are rated as:
Safe - good.
Effective – good.
Caring – Good (Carried through from the previous inspection in April 2022)
Responsive – good.
Well-led – good.
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:
- The provider had made improvements following the previous inspection and had employed a new practice manager and chairperson.
- The systems in place to ensure good governance had been reviewed and improved.
- The system for sharing patients diabetic care with secondary care had improved and ensured patients were appropriately followed up.
- The practice had put in place an effective system to ensure staff were appropriately trained.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Review and take action for all safety alerts.
- Continue to improve the uptake of childhood immunisations.
- Continue to improve the uptake of cervical screening by women.
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