Crown Street Surgery

Updated 7 November 2023

Crown Street Surgery is located in Swinton, South Yorkshire at:

Crown Street Surgery, 17 Crown Street, Swinton, South Yorkshire, S64 8NB.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures; maternity and midwifery services; and treatment of disease, disorder or injury.

The practice is situated within the South Yorkshire Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 9,400. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices, and is one of seven practices in the ‘Wentworth 1 PCN’ primary care network.

Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 98.1% White, 0.7% Asian, 0.7% Mixed, 0.4% Black and 0.2% Other.

The age distribution of the practice population showed there are more older people and fewer young people registered at the practice compared to local and national averages.

There are 2 GP partners working in a management capacity. The clinical care was provided by a team of 2 salaried GPs, 2 long-term locum GPs, 6 GP locums and a GP registrar and a team of nurses comprising 2 advanced nurse practitioners, 3 practice nurses including a lead nurse and a treatment room nurse. They were supported by a trainee nurse associate, a healthcare assistant and a phlebotomist. Two practice/finance managers provide managerial oversight and oversaw a team of administration and reception staff. A nurse associate, clinical pharmacist, 2 pharmacy technicians, a social prescriber link worker and a care coordinator were provided via the Additional roles Reimbursement scheme (ARRS). This scheme entitles Primary Care Networks (PCN) to utilise funding to support additional recruitment for specific roles.

Extended access is provided locally by Connect Healthcare Rotherham CIC, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.

Updated 7 November 2023

We carried out an announced focused inspection at Crown Street Surgery on 16 and 17 August 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective - requires improvement.

Caring – Not inspected rating of good carried over from previous inspection.

Responsive – requires improvement.

Well-led - requires improvement.

Following our previous inspection on 16 and 19 May 2022, the practice was rated requires improvement overall and for the safe, effective and well led key questions, but we rated the location as good for the caring and responsive key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Crown 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 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 short 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:

• Whilst there were some improvements and the practice had clear systems, practices and processes to keep people safe and safeguarded from abuse these were not always fully implemented.
• Patients mostly received effective care and treatment that met their needs. We found improved care for patients with diabetes and improvements in some aspects of asthma care. However, there was limited monitoring of the outcomes of care and treatment.
• Staff had not always received all the required training.
• Patients could not always access care and treatment in a timely way.
• There were clear responsibilities, roles and systems of accountability to support good governance and management but there was a lack of management oversight in some areas.

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:

• Improve the uptake of cervical cancer screening.
• Develop a programme of quality improvement and clinical audit that is aimed at improving the quality of patient care.
• Improve the systems to monitor urgent referrals have been actioned.
• Review and improve access.

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