Castle Street Surgery in Luton is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 18th March 2020
Castle Street Surgery is managed by Castle Medical Group Practice who are also responsible for 2 other locations
Contact Details:
Address:
Castle Street Surgery The Surgery Luton LU1 3AG United Kingdom
This practice is rated as Good overall. (Previous rating 02/2015 – Good)
The key questions at this inspection are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires Improvement
We carried out an announced comprehensive inspection at Castle Street Surgery on 21 November 2018 as part of our inspection programme to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
At this inspection we found:
There had been significant changes in the practice in the previous two years that had impacted on the culture of the practice. The practice had taken over Kingfisher Practice from another provider and made it a branch of Castle Street Surgery. The GP partners and the practice manager acknowledged that they were going through a period of adjustment.
The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Feedback from patients indicated they were satisfied with the care they received. However, they reported there was sometimes difficulty getting through to the practice by telephone to make appointments.
The practice had not maintained a record of staff vaccination in line with current Public Health England (PHE) guidance.
There was not an effective system to manage infection prevention and control (IPC). Staff had not received IPC training and IPC audits had not been completed.
The practice had not completed a formal risk assessment to determine which emergency medicines they needed to stock on the premises.
Reception staff had an awareness on identifying a deteriorating or acutely unwell patient. However, they had not received any formal training for this.
Appraisals had not been completed for all staff in the past year.
From the records we reviewed we found that the practice did not have documented personal care plans that were shared with relevant agencies
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:
Complete second cycles of clinical audits to demonstrate quality improvements had been made.
Develop ways to improve the uptake of patients who have been offered cervical cancer screening.
Make use of documented care plans that can be shared with relevant agencies.
Follow the complaints policy so all complaints are responded to within the recommended timeframes.
Continue to improve levels of patient satisfaction particularly in relation to access to the practice.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.
Letter from the Chief Inspector of General Practice
We visited Castle Street Surgery on the 10 November 2014 and carried out a comprehensive inspection.
The overall rating for this practice is good. However, there are some areas where improvement could be considered.
Our key findings were as follows:
Patients were satisfied with the service they received. They reported they were treated with dignity and respect and that they were not hurried during their consultation.
The practice had a good approach to ensuring that clinical care was up to date and in line with national guidance and carried out audit to determine the effectiveness of care.
There was an ethos of openness and honesty and staff reported feeling supported in their role.
The practice engaged well with the local clinical commissioning group to develop services and address the health needs of the practice population.
The practice had developed links with the local university to identify whether there were any young people who were suffering with anxiety or depression and who may have needed extra support.
However, there were also areas of practice where the provider needs to make improvements.
The provider should:
Develop a business strategy to manage risk and identify what action they would take if business continuity was compromised. This should specifically include risks regarding new premises proposed for next year and what they would do if the premises were not funded or built in time.
Introduce a more robust system to ensure that all staff are aware of lessons learnt from incidents, complaints and events that take place in the practice. There should be a regular meeting with all staff both clinical and administrative to facilitate this.
Carry out an audit of infection control and ensure that a process is introduced to ensure that monitoring of infection control takes place.
Ensure that the extended hours appointments are advertised in the practice leaflet and the website.