Background to this inspection
Updated
19 February 2021
- The provider of this service is Virgin Care Services Limited. Church Lane Surgery is a GP practice located in Braintree and is part of the Mid-Essex Clinical Commissioning Group.
- Church Lane Surgery is situated within the Colchester Institute Braintree Campus.
- There are approximately 10,300 patients registered at the practice.
- The practice is registered to provide the following regulated activities: treatment of disease, disorder or injury; diagnostic and screening procedures, maternity and midwifery services and family planning.
- Clinicians are supported by a service manager, assistant service manager and a team of reception and administrative support. There is also additional support and guidance from the Virgin Care Services regional and national teams.
- The surgery does not offer bookable appointments at weekends. For non-emergencies outside of the opening times patients access the national 111 service.
- There is comprehensive website providing information for patients to understand and access services, including useful contacts for specialist support services.
Updated
19 February 2021
We carried out an announced comprehensive inspection at Church Lane Surgery on 02 December 2020. This inspection was to follow up on breaches of regulation identified at a previous inspection in November 2019 and to provide new ratings for the practice.
We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews between 25 November and 1 December 2020 and carried out a site visit on 02 December 2020.
We had scheduled an inspection earlier in the year to follow up on breaches and determine if the practice could be removed from special measures, however, this was cancelled due to the COVID-19 pandemic.
There have been four previous inspections of this practice, three of which were comprehensive inspections where ratings were awarded and one, a focused inspection.
We initially carried out a comprehensive inspection on 08 August 2018. At this inspection the practice was rated as inadequate overall and placed into special measures for a period of six months. The practice was issued with a warning notice.
A focused inspection was undertaken on 19 December 2018 to check that the practice had made the necessary improvements required, as highlighted in the warning notice. We found that they had complied with the warning notice, however further improvements were required.
On 26 March 2019, we carried out a comprehensive inspection to confirm that the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections. At this inspection, the practice was rated as requires improvement overall and inadequate for all population groups. They were placed in an extended period of special measures.
We then carried out an announced comprehensive inspection on 21 November 2019. This was to check that the practice had made improvements as identified in our previous inspection in March 2019. At this inspection, the practice was rated as requires improvement overall, with a rating of good for safe and well led services, requires improvement for providing effective, caring and responsive services. All populations groups were rated as requires improvement, however the population group with people with long term conditions remained inadequate, therefore they remained in special measures.
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.
At this inspection we have rated this practice as good overall.
We rated this practice as requires improvement for responsive because:
- Patient satisfaction regarding making and accessing appointments was below local and national averages. The practice had continued to take steps to improve since the last inspection, however the changes had yet to have a significant positive impact on patients being able to access care and treatment in a timely way
As this affected all population groups, they were also rated as requires improvement.
We rated this practice as good for safe because:
- The practice had systems in place to manage risks.
- Medicines were managed effectively.
- The practice demonstrated ongoing quality improvement monitoring.
- There were clear and effective processes for managing infection prevention and control.
We have rated this practice as good for effective because:
- Clinical outcome indicators were in line with local and England averages.
- Staff worked together and with other organisations to deliver effective care and treatment.
We rated the practice good for caring because:
- Patient satisfaction results had improved and a continued commitment to improvement was evident.
We rated this practice as good for well-led because:
- We found that leaders had oversight of the systems and processes.
- There were clear responsibilities, roles and systems of accountability to support good governance and management.
- There were clear and effective processes for managing risk, issues and performance.
- Leaders and staff working at the practice had a commitment to improve.
The areas where the provider should make improvements are:
- Improve the coding and recall of patients with a potential diabetes diagnosis, to ensure they receive the appropriate care and treatment.
- Ensure medication reviews are undertaken in a timely manner.
- Continue to improve patient satisfaction in relation to appointments, contacting the practice by phone and overall experience.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care