The Care Quality Commission
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  • GP practice

Archived: Chapel Street Medical Centre

Overall: Requires improvement read more about inspection ratings

87 Chapel Street, Lye, Stourbridge, West Midlands, DY9 8BT (01384) 897668

Provided and run by:
Dr B Prashara & Dr D Prashara

Important: The provider of this service changed. See new profile
Important: The provider of this service changed - see old profile

All Inspections

21 October 2021

During an inspection looking at part of the service

We carried out an announced inspection at Chapel Street Medical Centre on 21 October 2021. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in warning notices we issued to the provider in relation to Regulation 17 Good Governance.

At the last inspection in June 2021 we rated the practice as Requires Improvement overall. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

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

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 found that:

  • The practice had complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
  • We found that patients who were treated with medicines that required additional monitoring had received the appropriate blood tests prior to prescribing.
  • The practice had reviewed and improved systems to manage patient safety alerts. Records we checked showed that most alerts were actioned appropriately. Where we found gaps, we discussed these with the practice. The practice told us of the action they were taking immediately after the inspection to improve systems further.
  • The practice had reviewed and improved their systems to manage patients at risk of developing diabetes.
  • The practice had reviewed and improved processes to more effectively manage recruitment files and staff training.

Whilst we found no breaches in regulation, the provider should:

  • Continue to review and improve systems to manage safety alerts.
  • Continue to review and improve systems to manage recruitment files.

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

21 and 24 June 2021

During an inspection looking at part of the service

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

4 March 2020

During an inspection looking at part of the service

We carried out an inspection at Chapel Street Medical Centre on 4 March 2020 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.

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

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 and requires improvement for the safe, effective and well-led domains.

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

Overall we found that:

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way
  • The way the practice was led and managed promoted the delivery of person-centred care.

We rated the practice as requires improvement for safe because:

  • Not all the recruitment documents required under current legislation were available for all members of staff employed by the practice. Appropriate checks or risk assessments to mitigate potential risks had not been completed for clinical and non-clinical staff who carried out their role or who chaperoned.
  • The process for managing high risk medicines needed strengthening.
  • The practice did not have all medicines to cover emergencies that may occur.
  • Significant events needed further embedding as opportunities to raise significant events had been missed.

We rated the practice as requires improvement for effective because:

  • The practice had not met the minimum 90% target for all four childhood immunisation uptake indicators. The uptake of the immunisation for the percentage of children aged one who have completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b was significantly below target.
  • Screening rates for breast cancer and bowel cancer were below local and national averages.
  • Cervical screening rates were significantly below the national target.
  • We found gaps in high risk medicines and some patients had not had appropriate monitoring before the medicine was prescribed.

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

  • Actions to address challenges were not always clearly identified and implemented.
  • There was no clear strategy that identified priorities or consistent action to achieve them.
  • The overall governance arrangements were not consistently effective.
  • Arrangements for identifying, managing and mitigating risks were not always effective.
  • Systems and processes for learning and improvement were not consistently effective.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Develop an effective system to review and monitor infection control.
  • Continue work to increase the uptake for cervical, breast and bowel screening.
  • Continue work to increase the child immunisation rates.
  • Develop a process of delegation in the absence of the practice manager.
  • Further review and embed the process for significant events.
  • Review arrangements for appraisals and support mechanisms for staff to ensure that learning and development needs are addressed.

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

20 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Street Medical Centre on 20 January 2015. We rated the practice as good overall.

Specifically, we found the practice to be good for providing effective, caring, responsive and well-led services. It was also good for providing services for the six population groups. It required improvement for providing a safe service.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed.
  • The management of risks to patients was not robust. Some risks to the practice had been identified and addressed, but we found a number of areas during our inspection in which risks identified had not been appropriately assessed and acted on such as the provision of appropriate emergency equipment and medicines and legionella testing.
  • Patients’ needs were assessed and care was planned and delivered according to best practice guidance. Staff had received training appropriate to their roles and further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect, although patients felt being involved and making decisions about their care treatment was an area for improvement.
  • Information about services and how to complain was available and easy to understand but was not clearly displayed in the practice.
  • Most patients said they found it easy to make an appointment with a named GP, urgent appointments were available on the same day. However, feedback from patients indicated patients were not satisfied with the practice opening hours.
  • The practice had adapted the premises to ensure disabled patients could access the service. Facilities were also available for those with young children.
  • There was a clear leadership structure and staff felt supported by management. However, there were areas the practice needed to improve on such as the management of risks including those relating to patient satisfaction.

However there were areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure that robust and effective systems are put in place to protect patients from the risks of unsafe care such as not having certain emergency equipment and medicines and the absence of legionella testing.
  • Ensure audits complete their full audit cycle in order to demonstrate improvements made to practice.
  • Review how the service can improve patient satisfaction in relation to involvement in care, treatment decisions and accessibility to the practice in relation to opening hours and appointments.
  • Ensure all staff who act as chaperones have a DBS check or should be risk assessed as to whether a DBS is needed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice