Chapel Lane Surgery

Background to this inspection

Updated 24 July 2017

Chapel Lane Surgery is based in Formby town centre. There were approximately 8,050 patients on the practice register at the time of our inspection.

The practice is managed by four GP partners. There is also a salaried and sessional GP. There are two advanced nurse prescribers, five practice nurses and two health care assistants. Members of clinical staff are supported by two interim practice managers, reception and administration staff.

The practice is open 8am to 6.30pm every weekday. The practice offers extended hours

on one evening each week between 6.30pm and 8.30pm. The practice closes on one Wednesday afternoon per month for staff training. Patients requiring a GP outside of normal working hours are advised to contact the GP out of hours service by calling 111.

The practice has a Personal Medical Services (PMS) contract and has enhanced services contracts which include childhood vaccinations. The practice is part of Southport and Formby Clinical Commissioning Group.

Overall inspection

Good

Updated 24 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Lane Surgery on 17 November 2016. The overall rating for the practice was requires improvement with requires improvement for safe, effective and responsive services, inadequate for well led and good for providing a caring service. The full comprehensive report on the 17 November 2016 inspection can be found by selecting the ‘all reports’ link for Chapel Lane Surgery on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 30 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 17 November 2016. This report includes our findings in relation to those requirements.

Overall the practice is now rated as good for providing services.

The practice had made significant improvements and addressed the issues identified in the previous inspection. The practice engaged all staff in driving forward improvements and utilised new technology. Improvements included:

A review of the governance systems in place to ensure the quality and safety of the service. All policies and protocols had been revised. The practice now utilised a computer software programme to help monitor systems.
All staff had received mandatory training relevant to their role and had received an appraisal. There was now a system in place to monitor the training and appraisals staff received.
Recruitment checks were in place for all staff. Staff were asked to update their DBS checks at annual appraisals.
There were increased monitoring systems now in place for cleaning and the safety of the premises. This included having a fixed electrical wiring safety certificate for the premises.
Improvements in the content of patient specific directions for nursing staff to administer medicines safely.
A system to review any abnormal screening checks for patients.
Responding to patient feedback about making appointments and waiting to be seen beyond their allocated time by engaging with the PPG and Healthwatch and working towards the national New Ways of Working programme. The practice had implemented a system of triaging patient calls and trained staff to become care navigators to signpost patients to the most appropriate service instead of automatically being booked in with a GP. To support this, the practice had recruited a variety of new staff such as a phlebotomist and an advanced nurse practitioner.
Clinical meetings were now documented.
The practice had correctly registered with us to carry out the regulated activity of family planning.

In addition:-

The practice had a new carers’ policy and actively sought ways to identify carers by utilising a carer’s questionnaire available in the waiting room and offer tailored support.
The practice had reviewed its safeguarding registers.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice