Archived: St Thomas Road Surgery

Updated 8 December 2021

St Thomas Road Surgery is located in Derby at:

207 St Thomas Road

Derby

DE23 8RJ

The provider (One Medicare Ltd) is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is a member of the NHS Derby and Derbyshire Clinical Commissioning Group (CCG) and delivers primary care services via an Alternative Provider Medical Services (APMS) contract, and offers a range of local enhanced services, to a patient population of about 4,428 patients. This is part of a contract held with NHS England. The practice is part of Greater Derby Primary Care Network, a wider network of 11 GP practices that work collaboratively to deliver primary care services.

Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others.

The age profile demonstrates a significantly lower proportion of older patients compared to the local and national averages, and significantly higher numbers of younger patients compared to local and national averages:

• The percentage of older people registered with the practice is 4.6% which is significantly below the CCG average of 20.3%, and the national average of 17.6%.
• The percentage of working age people registered with the practice is 62.3% which is above the CCG average of 60.2%, and in line with the national average of 62.3%.
• The percentage of young people registered with the practice is 33% which above the CCG average of 19.5%, and the national average of 20.1%.

According to the latest available data, the ethnic make-up of the practice area is 48.6% White, 37.6% Asian, 4.3% mixed race, 5.9% Black and 3.6% other groups.

The team is led by a clinical service manager, supported by a business manager, reception manager and team of reception staff and includes a practice nurse, assistant practitioner and wellbeing advisor. There are regular sessional GPs and Advanced Clinical Practitioners. Practice staff receive ongoing support from the wider infrastructure within One Medicare Ltd.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most clinician appointments are telephone consultations. If the clinician needs to see a patient face-to-face then the patient is offered an appointment.

Extended access is provided by a collaboration of local practices, where late evening and weekend appointments are available. Out of hours services are provided by Derbyshire Health United.

Further information about the practice is available via their website at: www.onemedicalgroup.co.uk/surgeries/st-thomas-road-surgery

Updated 8 December 2021

We carried out an announced inspection at St Thomas Road Surgery on 2 and 9 November 2021. Overall, the practice is rated as good and good in all key questions.

Following our previous inspection on 28 October 2020 the practice was rated Requires Improvement overall and for safe, effective and well-led, and good for responsive and caring.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Thomas Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

• The key questions safe, effective, caring, responsive and well-led
• Breaches of regulation relation to governance.
• Four best practice recommendations

How we carried out the inspection/review

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 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 had actioned and put measures in place for all the improvements areas identified in the previous inspection, including the breaches in regulation.
• Staff spoke highly about the management team and commented that leaders were visible and approachable. Staff felt supported and valued in their work.
• The management team understood the strengths and challenges relating to the quality and future of services. They had identified the actions to address the challenges, for example, reviewing all job descriptions and benefits, reviewing the needs of the practice population in the relation to staffing and skill mix, and consideration of alternative staffing models.
• 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 had the skills, knowledge and experience to carry out their roles. There was a system in place to monitor compliance with staff training. Staff were encouraged and supported to develop their skills and move to new roles with the practice.
• Systems were in place to assure the provider of the competency of staff working in advance roles.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice 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.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Governance arrangements had been strengthened, become embedded and were working effectively.

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

• Continue to promote and drive the uptake of childhood immunisations and cancer screening programmes with their patients.
• Update the practice website with a greater focus on information on local support services.

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