Archived: Chapel Street Medical Centre

Updated 16 November 2021

Chapel Street Medical Centre is located in Stourbridge, West Midlands:

87 Chapel Street

Lye

Stourbridge

West Midlands

DY9 8BT

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

The practice is situated within the Black Country and West Birmingham Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 2,650. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices in the Stourbridge, Wollescote and Lye Primary Care Network (PCN).

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

The National General Practice Profile states that 70% of the practice population is from a white ethnic background with a further 30% of the population originating from black, Asian, mixed or other non-white ethnic groups.

The clinical team includes two GP partners (one male and one female). At the time of our inspection only one GP partner was carrying out clinical duties at the practice and was supported by two locum GPs and a part time nurse.

The clinical team are supported by a part time practice manager, and a team of receptionists and administrators.

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 are telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of appointment.

Extended access is provided locally by Stourbridge, Wollescote and Lye Primary Care Network (PCN), where late evening and weekend appointments are available. Out of hours services are provided by West Midlands Ambulance Service via NHS 111.

Updated 16 November 2021

We carried out an announced inspection at Chapel Street Medical Centre on 21 and 24 June 2021. Overall, the practice is rated as requires improvement.

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous inspection on 12 February 2020, the practice was rated requires improvement overall and for all keys questions of safe, effective and well-led and good for providing caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Chapel Street Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This was a focused inspection to follow up on:

• The safe, effective and well-led key questions
• Any breaches of regulations or ‘shoulds’ identified at our last inspection.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive.

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. All the population groups have been rated as good with the exception of families, children and young people and working age people (including those recently retired and students) and people with long term conditions which are rated as requires improvement.

We rated the practice as inadequate for providing safe services because:

• We identified issues with recruitment processes and ongoing employment checks for staff working at the practice and this had been identified at our last inspection.
• We found concerns in relation to the monitoring of high-risk medicines which had been identified at our last inspection.
• The practice had made improvements in their infection prevention and control procedures and this was being managed effectively.
• There were systems and processes for learning from significant events. We saw that meetings were being held with staff where this had been reviewed.
• The system for managing safety alerts needing embedding further as we found that a drug alert had not been actioned appropriately.

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

• The practice had established an action plan to address areas of low performance since our last inspection and there had been some improvement in some of their childhood immunisation outcomes, however uptake remained significantly below the World Health Organisation (WHO) targets.
• The practice had seen some areas of improvement in uptake with cancer screening, however the actions they had taken to improve uptake had not yet been fully effective and uptake remained significantly below the Public Health England coverage target.
• The practice had recruited non-clinical staff since our last inspection to help support with non-clinical areas however, we found staff training was not being effectively monitored and the practice could not demonstrate that staff had completed the necessary training.
• The provider had acted to address the concerns we found during the last inspection, however, some governance systems remained ineffective as not all actions had been fully embedded. As a result, we continued to find gaps in the monitoring and management of patients with long term conditions on high risk medicines.
• The provider had reviewed its strategy as part of its succession planning and had taken steps to review the quality and sustainability of the practice.

We found the following breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found breaches of regulations, the provider should:

• Continue work to increase the uptake for cervical, breast and bowel screening.
• Continue work to increase the child immunisation rates.

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