Church Street Surgery

We carried out an announced inspection at Church Street Surgery on 28 July 2022.

Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 2 August 2017, the practice was rated Good overall and rated good in safe, effective, caring and well-led and rated requires improvement for responsive.

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

Why we carried out this inspection

This inspection included a comprehensive review of information and a site visit where we inspected safe, effective, responsive and well-led care. Additionally, we reviewed access to the practice via telephone and a patient’s ability to book in with named GP’s.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. Therefore, as part of this inspection we completed clinical searches on the practice’s patient records system and discussed the findings with the provider. This was with consent from the provider and in line with all data protection and information governance requirements.

The inspection also included:

• Requesting and reviewing evidence and information from the service
• A site visit
• Conducting staff interviews
• Reviewing patient records to identify issues and clarify actions taken by the provider

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 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 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.
• The practice had a culture which drove high quality sustainable care. However, no freedom to speak up guardian was in place at the service, despite this staff we spoke with could describe what actions they would take and who they would speak with if they had concerns.
• The practice overall had systems for the appropriate and safe use of medicines, including medicines optimisation, however these did not always work as intended, specifically appropriate authorisations of Patient Group Directions PGD’s were not available at the time of inspection.
• The practice has addressed the concerns raised in the 2017 National GP Patient survey with the 2021 National GP Patient survey showing improvements in almost all areas, including responses related to accessing care by telephone. Additionally, we found the practice responsive in its approach towards patients and the treatment it delivered.

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

• Explore systems to ensure all environmental risks were being reviewed and mitigated.
• Strengthen systems for appropriate and safe use of medicines.
• Ensure that a Freedom to Speak Up Guardian is appointed.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services