Background to this inspection
Updated
7 July 2021
The Surgery York Road is located in Rotherham at:
- The Surgery York Road, York Road, Rotherham, S65 1PW
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures; family planning services; maternity and midwifery services; surgical procedures; and treatment of disease, disorder or injury. The practice is registered as a partnership between two Registered Managers; however, at the time of our review, we saw one of the Registered Managers had left the practice and saw the provider's registration had not been updated.
The practice offers services from the main practice location only and operates from 8am to 6.30pm every weekday.
The practice is situated within the NHS Rotherham Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 4,500. This is part of a contract held with NHS England.
The practice is part of the Wentworth 1 Primary Care Network, which consists of seven member practices with a total patient population of approximately 56,000.
Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one out of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available date, the ethnic make-up of the practice area is 78.7% White, 14.5% Asian, 2.4% Black, 2.2% Mixed and 2.2% Other.
There is a team of three GPs, which includes two locum GPs. The practice has a team of three nurses and one healthcare assistant who provide nurse-led clinics for the management of long-term conditions. The GPs are supported at the practice by a team of reception and administration staff. The practice manager is based at the practice to provide managerial oversight.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment at the practice.
Extended access is provided locally by Connect Healthcare Rotherham, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.
Updated
7 July 2021
We carried out a desk top follow up inspection at The Surgery York Road on 6 July 2020. This inspection was to follow up a previous inspection of
Dr Naranammalpuram Srinivasan,
in November 2018. During that inspection a new provider was registering with the Commission to take the service over.
We rated the practice as requires improvement for providing effective services because:
- The practice’s performance on quality indicators for some long-term conditions and cancer indicators for working age people was significantly below local and national averages. Although some progress had been made there was limited improvement seen at the time of inspection.
At this inspection, we found that the new provider had satisfactorily addressed most of these areas.
We based our judgement of the quality of care at this service on a combination of:
- Documentation and information from the new provider and information from our ongoing monitoring of data about services.
We have rated this practice as good for being effective and good overall and for all population groups apart from working age people which is rated as requires improvement.
We rated the practice good for providing effective services because:
- The practice's performance on quality indicators for those with some long-term conditions had improved and were mostly
in line with local and national averages.
-
However, performance data for cervical cancer screening was significantly below local and national averages. The practice remains requires improvement for the working age people population group.
In addition, the new provider shared with us the actions they had taken as a result of the areas we told them they should improve in the November 2018 inspection report.
- Risk assessments had been completed relating to blind cords, hot water and emergency medicines. As a result blind cords had been secured to the wall with cleats. Water temperature checks had been completed and hot water warning signs installed. Emergency medicines were checked weekly.
- An infection prevention and control (IPC) action plan had been developed from the August 2019 IPC audit. Actions had been completed in accord with the findings.
- An up to date record of staff immunisation status was now kept.
- Staff routinely asked patients during consultations whether they had a caring responsibility and would offer support accordingly. A notice board in the waiting area was designated to provide local information and support groups for carers. There were 43 patients registered at the practice with caring responsibilities which represents 1% of the practice population.
- The number of pre-bookable and same day appointments was increased by employing two advanced nurse practitioners and three GP locums. Extended hours appointments were available on Tuesday evenings until 7.45pm.
Whilst we found no breaches of regulations, the provider
should
:
- Continue to review the uptake of cervical cancer screening with a view to improving achievement.
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