The Care Quality Commission
  • Doctor
  • GP practice

Regent Square Group Practice

Overall: Good read more about inspection ratings

8-9 Regent Square, Doncaster, South Yorkshire, DN1 2DS (01302) 819999

Provided and run by:
Regent Square Group Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Regent Square Group Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Regent Square Group Practice, you can give feedback on this service.

27 and 28 June 2022

During an inspection looking at part of the service

We carried out an announced inspection at Regent Group Practice on 27 and 28 June 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 26 May 2021 the practice was rated Requires Improvement overall, inadequate in safe, requires improvement for effective and good in caring, responsive and well led. The rating of good for caring and responsive has been carried forward to the June 2022 inspection as we were satisfied that this was still relevant.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Regent Square Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a follow-up inspection to follow up on:

  • Breaches of regulations and recommendations identified in the previous inspection.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • Staff feedback
  • 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 have rated this practice as Good overall

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. The practice had made improvements since the last inspection, through proactively reviewing medicines management via routine clinical searches and clinical audits.
  • Patients received effective care and treatment that met their needs. Clinical searches and medical records we reviewed showed effective management and monitoring of patients with long-term conditions although there were some areas that required review.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Continue to monitor the register of patients on high risk medicines and take action to support safe prescribing if patients do not attend.
  • Continue with plans to follow up patients to check response to the treatment within a week of an acute exacerbation of asthma.
  • Continue with plans to monitor tasks and blood test results are managed effectively.
  • Continue with plans to improve uptake of cervical cytology screening and childhood immunisations.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

26 May 2021

During an inspection looking at part of the service

We carried out an announced inspection at Regent Square Group Practice on 26 May 2021. Overall, the practice is rated as Requires improvement.

Safe - Inadequate

Effective - Requires improvement

Well-led - Good

Following our previous inspection on 11 February 2020, the practice was rated Requires Improvement overall and for safe and well led.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Regent Square Group Practice on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

  • Breach in Regulation 12 Safe care and treatment at the inspection in February 2021.

At the last inspection the practice was rated good for caring and responsive and this was carried forward to this inspection.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • 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 have rated this practice as Requires improvement overall, inadequate for the safe key question and requires improvement for the effective key question. It was rated as good for the provision of caring, responsive and well led services. We rated population groups people with long term conditions, working age people, children, families and young people and people whose circumstances make them vulnerable as requires improvement.

We found that:

  • The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • Patients’ needs were assessed, but care and treatment were not always delivered in line with current standards and evidence-based guidance in relation to reviews of patients with long term conditions and a learning disability.
  • Some performance data was below local and national averages and evidence overtime showed the practices attainment had been declining pre-covid in relation to cancer screening and childhood immunisations.
  • Systems did not ensure blank prescriptions were stored securely.
  • There was no evidence oxygen cylinders were being checked daily.
  • Historic medicine safety alerts had not been routinely actioned.
  • The practice did not routinely review through quality improvement the effectiveness and appropriateness of the care provided in order to provide effective, safe care.
  • There was no system for monitoring of non-emergency medicines.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centered care.

We found breach of regulations. The provider must:

  • Improve systems to ensure proper and safe management of medicines.

The provider should:

  • Improve the process for authorising Patient Group Directives (PGD), for example, some had been authorised after staff have signed them.
  • Update records for vaccinations and immunisation training
  • Improve systems to ensure the registration of clinical staff is checked
  • Revisit infection prevention and control audits to ensure adherence to the practices policy.
  • Develop a refurbishment plan.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

11 February 2020

During an inspection looking at part of the service

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe, effective and well led.

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 have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • The practice had not always implemented systems and processes in areas such as recruitment and training, infection prevention and control, patient confidentiality and medicines management to keep people safe and safeguarded from abuse.

We rated the practice as Good for providing effective services because:

  • Patients received effective care and treatment that met their needs.

We rated the practice as requires improvement for providing well led services because:

  • The governance arrangements did not always operate effectively and the provider did not have clear and effective processes for managing risks, issues and performance.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Review and improve staff access to practice policies and procedures.

  • Review and improve staff training in preparation for major incidents.

  • Continue with plans to obtain a DBS check for one member of staff.

  • Continue with plans for non-clinical staff appraisals.

  • Review and improve systems to monitor staff training.

  • Staff are clear of their roles and responsibilities, for example non-clinical staff do not act as chaperones.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

To Be Confirmed

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced inspection at Regent Square Group Practice on 27 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, families, children and young people and the working age population.

Our key findings across all the population group areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and managed, including those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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. Complaints would be addressed in a timely manner and the practice endeavoured to resolve complaints to a satisfactory conclusion.
  • 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice