The Care Quality Commission
  • Doctor
  • GP practice

Church Street Partnership

Overall: Good read more about inspection ratings

30A Church Street, Bishops Stortford, Hertfordshire, CM23 2LY (01279) 657636

Provided and run by:
Church Street Partnership

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Church Street Partnership on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Church Street Partnership, you can give feedback on this service.

29 January 2020

During an annual regulatory review

We reviewed the information available to us about Church Street Partnership on 29 January 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

9 October 2018

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Street Partnership on 19 September 2017. The overall rating for the practice was good with requires improvement for providing responsive services. The full comprehensive report on the 19 September 2017 inspection can be found by selecting the ‘all reports’ link for Church Street Partnership on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 October 2018 to confirm that the practice had made the recommended improvements that we identified in our previous inspection on 19 September 2017. This report covers our findings in relation to those improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

  • The practice had comprehensive systems in place to collect and review patient feedback and audit their telephone and appointment booking systems. An improvement plan had been implemented in order to increase access for patients and enhance their experience of using the practice.
  • Leaders had committed to improving performance and patient access and had invested in employing additional staff and upskilling existing staff members.
  • Patients told us that they were able to obtain an appointment that was convenient to them and patient feedback demonstrated that the changes introduced by the practice had resulted in some improvements.

The area where the provider should make improvements is:

  • Continue to review and ensure improvement to the National GP Patient Survey results, including access to the practice by telephone.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

19/09/2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Church Street Partnership on 30 August 2016. Overall the rating for the practice in 2016 was requires improvement; specifically it was rated requires improvement for safe, effective, responsive and well-led. During our inspection in August 2016 we identified regulatory breaches in relation to;

  • Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- good governance.

The full comprehensive report from the August 2016 inspection can be found by selecting the ‘all reports’ link for Church Street Partnership on our website at www.cqc.org.uk.

We carried out a further announced comprehensive inspection on 19 September 2017; overall the practice is now rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patient comments highlighted that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvements are:

  • Continue to review and ensure improvement to the national GP patient survey results, including appointment waiting times, access to the practice by telephone and pre-bookable appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30/08/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Street Partnership on 30 August 2016. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 21 May 2015. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. However, the practice did not carry out an analysis of the significant events over time to identify trends.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients told us that urgent appointments were available on the same day. However, patients found it difficult to get through to the surgery on the telephone and to book appointments in advance.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Ensure that systems are implemented to assess the risk of and to prevent, detect and control the spread of infection including routine audit processes.
  • Ensure that all staff employed receive essential training relevant to their role including children and adult safeguarding and infection control.

The areas where the provider should make improvements are:

  • Ensure an appropriate system is in place for the safe use of blank prescription forms and pads and the management of uncollected prescriptions.
  • Ensure review of systems and processes for the effective management of patients with long term conditions.
  • Develop a process to ensure a consistent approach towards receiving and managing patient safety alerts.
  • Carry out an analysis of significant events to identify trends.
  • Ensure steps are taken to make improvements to the National GP Patient Survey results; including access to routine pre-bookable appointments, appointment waiting times and access to the practice by telephone.
  • Review and make improvements to the baby changing area and disabled patient toilet facilities provided in line with the requirements of the Equality Act 2010.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Street Partnership on 21 May 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well led services. It was good for providing a caring, effective and responsive service.

We also found the practice to be good at providing services for older people, those with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable, and people experiencing poor mental health, including people with dementia. As the provider was rated as requires improvement for safety and for well-led, the concerns which led to these ratings apply overall to everyone using the practice, including the population groups.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded and assessed but was not always monitored, reviewed and addressed appropriately.
  • Data showed patient outcomes were average for the locality. Audits had been carried out and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested. However, patients said that they sometimes had difficulty getting through on the telephone.
  • The practice had a number of policies and procedures to govern activity but there were some omissions and policies were not always followed and monitoring processes were not always robust.
  • The practice had proactively sought feedback from patients but did not actively seek feedback from non-clinical staff or provide an opportunity for them to meet as a team or give feedback on performance through appraisal.

The areas where the provider MUST make improvements are:

  • Establish systems and processes to assess risks and implement actions to ensure the health and safety of people who used the service including those related to infection control, checking of emergency medicines, emergency equipment, legionella risk assessments, fire procedures and safeguarding children and adults.
  • Introduce systems to provide reception and administration staff with appropriate on-going and periodic supervision, appraisal and staff meeting opportunities in their role to make sure their competencies are maintained.
  • Ensure that risk assessment or a Disclosure and Barring checks (DBS) are carried out for non-clinical staff that needed this check such as those carrying out chaperone duties.

Action the provider SHOULD take to improve:

  • Ensure robust systems are in place to monitor the checking of fridge temperatures, emergency medicines and equipment
  • Introduce means of gaining regular effective two way communication and involvement between management and reception and administrative staff and sharing of lessons learned from complaints and significant events.
  • Carry out fire drills to ensure staff know what to do in the event of a fire.
  • Ensure staff are trained in equality and diversity.
  • Continue to monitor and improve telephone access.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

 

15, 16, 23 January 2014

During a routine inspection

We spoke with 17 patients, three GPs and nine staff to help us assess whether this practice was compliant with the law. We found mixed evidence.

Not all patients felt they were treated with consideration and respect, or that their privacy and dignity was protected. There was a very proactive patient participation group and a commitment from the GPs to improve the service. We found that the arrangements in place to meet patients' diverse needs were not always effective.

Most patients told us that they received the care, support and treatment to meet their needs and maintain their health and wellbeing. Most patients were very complimentary about the doctors and the nurses and said their health was overseen and managed effectively. Patients commented, "Our GP has a very nice manner and is very good with children," and, "Doctors and nurses are well informed and knowledgeable." Several patients expressed concerns about the continuity of care, and said they would prefer to see a specific GP for long term conditions.

We found non-clinical staff did not have the training, supervision and support they needed to do their job well and to expected standards. Clinical staff were well supported and had opportunities for professional development.

We found the management of systems in place to ensure the service was delivered to an acceptable standard and in a way which minimised risks were not effective. Improvements were needed to make sure practice staff learned from comments and complaints patients made about the service delivery.